Vulnerable older people living in care homes are at higher risk of oral health problems and related conditions because of high levels of dependency and dementia.
Unfortunately as people advance with dementia they often become more resistant to mouth care. Admittedly, providing good oral care for residents that are uncooperative can be particularly challenging. 
Care staff are understandably less likely to want to approach and carry out mouth care in these cases. If regular oral care is not carried out, a vicious circle of pain, discomfort and impact to the general health leading to an increased likelihood to resistance. 

Downloadable Tips & Coping strategies for people that resist mouth care click HERE

 

Suggested Tips for People that Resist Mouth Care

There is no one solution for every individual person, and techniques which are found to be helpful may need to be adapted as a persons mental or physical health declines.

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Oral Care and Dementia

Residents with dementia may develop reflexes that make tooth brushing difficult such as closing their lips, clenching their teeth, biting and moving their head.  If this is the case it would be helpful to ask a family member who is more familiar with the resident to be present and help.

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Early Dementia     Able to care for their own oral health or will merely need reminding.

Mid – Late Dementia   May be unable to communicate that they are in pain. They may do this in other ways such as crying, pulling or hitting their face, hitting out at care staff, or being very passive.

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Resistance to oral care by people with dementia is most often a response to fear, and it is more helpful to view this behaviour as a sign of distress rather than the resident choosing to be aggressive and uncooperative.

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Here are some general considerations when approaching someone for mouthcare

• Quiet environment with good lighting

• Be calm and friendly, and smile.

• Talk clearly, at the resident’s pace.

• Explain in short sentences and in simple terms what you are doing.

• Try only to ask questions that require a yes or no answer.

• Use reassuring and appropriate body contact and gentle touch.

• Remain positive and try to refrain from showing any frustration.

• Think  about your attitude and body language as showing any frustration will be counter-productive.

• Letting them feel the toothbrush so that they know that it’s not going to hurt.

 

Position

When assisting someone with mouthcare, try and carry out brushing sitting down as you will be able to see better.  Come in front to greet the individual and talk and then deliver care from the side as this is better on your back and visibility. 

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Encourage Independence

NHS Scotland tips and coping strategies

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Do all you can to encourage as much independence as possible. Residents may exhibit less resistance when care staff encourage them to carry out their own oral care as it gives them a sense of control.

• Bridging –   ‘Follow my leader style’.

Describe and show the toothbrush to the resident, mimic brushing your own teeth, give a spare toothbrush to the resident, and the resident may mirror your behaviour and brush their own teeth

• Chaining – this involves gently bringing the resident’s hand to the mouth while describing the activity. Let the resident continue if they are able. –

• Hand over hand – if chaining is not successful, then place your hand over the resident’s and gently brush the teeth together.

• Distraction  -  Try singing or giving the  person something  to hold or do by placing a familiar item in the resident’s hand while you brush the resident’s teeth.

• Rescuing – Sometimes having someone new (rescue) take over the task works bringing a different approach, different manner which may encourage the resident to cooperate.

• Timing – The morning may simply not be the best time.  Having oral care after medication and breakfast may be better.

• Breaking the task down - It maybe that one side of the mouth gets brushed in the morning and the other side in the evening? Ensure that you note what area has been brushed so other staff are aware.

 

 

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What to do if someone doesn’t want mouthcare.

They may not be used to having someone else clean their teeth. 

• Try and engage in small talk

• Say things like, “I can see something in your mouth”. Try to find out why the person does not want you to carry out mouthcare and respond to this.

•  The individual may be tired? – come back later when the person may be more receptive.

• Pain – It may hurt them, be gentle, use a soft brush, run it under warm water. check for soreness, infection, broken teeth, etc. and take appropriate action.

•  Fear – provide reassurance; explain and if necessary what you are going to do on yourself.

•  Develop a routine (e.g. same time/same carers). 

• Try not to carry out all personal care procedures at once. 

 

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What to do if someone refuses to open

They may not understand you or may not want to have their teeth brushed. 

• If the person is agitated then come back another time.

• If someone doesn’t open then stroke the side of the cheek to encourage them to open their mouth

• Be reassuring.

• Say what you are going to do before you do it.

• Touch the mouth, or teeth gently with the brush to prompt opening.

• Place the back of the toothbrush against the lips and gently twist it so it opens the lips and touches the front teeth   Start by cleaning the outer surfaces of the front teeth. Then move to the outer surfaces of the back teeth

• Or….with a smile,  say that you’ll come back later.

 

The Good news is that once the mouth is open you can usually complete mouthcare.

 

Biting the toothbrush

• If someone bites down on the toothbrush whilst brushing have another brush handy to continue brushing the teeth. This gives you access to the inside of the teeth

• Gently rubbing the cheek or jaw – relaxes jaw to release the toothbrush

 

Sucking on the toothbrush

• This is an instinctive reflex.  Explain what you are doing, be gentle assure them you will be quick.

• Gently rub cheek to relax jaw muscle.

• Start by cleaning the outer surfaces of the front teeth. Then move to the outer surfaces of the back teeth.

• Ask the person to say ‘ah’ for cleaning the biting and inside surfaces.

• Give positive feedback and encouragement

 

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If someone show physical aggression

• Come back later; pick another time of day when the person is calmer and more receptive.

• Try someone the person is more familiar and relaxed with.

• Be patient, take time and be reassuring. Do not talk about the person but always to the person.

• Explain what you are going to do and why you are going to do it.

• Stay calm and quiet yourself.

• Look in the mouth for any signs of soreness, infection, broken teeth etc.

 

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If someone grabs your hand

Grabbing the hand is most common in the middle stage of dementia. 

• Stop what you are doing. They may not understand so explain what you are doing or they may be in pain.

• They may want to do the brushing themselves.  Give them the toothbrush, put your hand over theirs and guide them.

• If you notice bleeding, ulcers or sores be gentle and keep an eye on them.

 

Individual maybe anxious or scared 

• Get them to hold your hand whilst brushing for reassurance.

• Maybe get her refocused on something else. Massage shoulder as a distraction favourite programme, song.  

• Distraction Give them something to hold or touch distraction technique or Play music to calm them.

 

Unable to spit

• Dampen the toothbrush in mouthwash or use a smear of toothpaste, preferably non foaming.

• Put a cup under mouth although they may associate the cup with drinking and not spit into the cup but over it.  If this is the case then put the person near a sink for spitting.

• Do not put addition fluid mouth in the mouth

• Ensure that they are sat up

• Use a gauze to remove excess fluid or use a suctioning toothbrush.

 

Denture Care

• Get the individual to take their own dentures out.  It takes patience.

• They may not let you take them out.   Give a reason for taking dentures out like making the dentures feel fresh and clean. If they don’t understand use simple sentences, rub the cheek

• To put denture back in Touch lip with the denture.  You may need to use denture fixative if loose.

• Clasps. May clip onto loose teeth.

 

What to do if someone continually refuses mouthcare

 If a resident refuses mouth care on several consecutive attempts, this should be escalated to a senior nurse or their medical team

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Who should consult with one of the following:

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• dementia Liaison or Community Mental Health teams

• the resident’s dentist if they have one or healthcare professional

• your local NHS Dental Helpline for advice and information on which dentists in your area can help.

 

 

Mental Capacity Act 2005.

Acting in the best interests of someone lacking capacity to make a decision for themselves

People who work with or care for others who lack capacity to make decisions have a legal duty to consider the Code of Practice. Any care provided should be in the patient’s best interests and be the least restrictive on the individual’s rights and freedom of action. It is important to make every attempt to support a patient with mouth care, a failure to do means neglecting them of care.

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If issued with a certificate of Incapacity

All regular personal healthcare (oral care is included) is to be given despite resistance – but the principles of the Incapacity Act must still be upheld. Consideration should also be given to local policies and the resident’s care plan.

One of the key principles of the Act is that any act done for, or any decision made on behalf of a person who lacks capacity must be done, or made, in that person’s best interests.

As long as these acts or decisions are in the best interests of the person who lacks capacity to make the decision for themselves, or to consent to acts concerned with their care or treatment, then the decision-maker or carer will be protected from liability.

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Transforming Mouth Care Challenges into Success  Download presentation HERE

No More Fighting and Biting During Mouth Care: Applying the Theoretical Constructs of Threat Perception to Clinical Practice,   Rits  A Jablonski et al. PMC 2012 HERE