Mouth & Oral Care for the Dependent Adult by Ann Ossinger, RDH, BSDH, EPP 11/22/2013
Good oral care is essential. Not just to reduce dental or oral disease, but to provide comfort, for quality of life, to enable healthy eating, to reduce pain, to reduce infection, to reduce inflammation and, maybe most importantly for the dependent adult, to reduce pneumonia which is one of the leading causes of hospitalization and death among this special population. We also know that poor oral care can exacerbate diabetes, heart disease and other health issues.
OK, so now we know it is important. What does providing good oral care mean? And how do you do it?
Did you know that it takes about 14 separate steps to brush and floss your teeth? Most of us do this almost unconsciously. We hardly think about it since we just follow our habits at bedtime and when we wake up.
For a patient who might forget, or has difficulty with the dexterity required, or who might choke easily, or is completely dependent –we need to provide assistance of some sort. Maybe we just need to remind them to brush. Maybe we need to remind them for each step of the process. Maybe we need to provide all the care needed. Whatever level is required though, we need to let the adult do as much as they can on their own, while still making sure the job has been done thoroughly. That is tough! It isn’t easy to provide care if the care isn’t wanted, or if there is active resistance.
Well I’m here to help! I’m here to provide some answers and provide a list of tips, tricks, and products to try.
First, I’m going to talk about products. There are SO MANY PRODUCTS out there!! Here is a partial list of products that I like and that my patients like. Pick and choose as needed, depending on YOUR PATIENT, I will give recommendations for different scenarios. Every patient is unique, and what works for one person won’t necessarily work for another.
Brushes: A somewhat independent adult may just use the brush they have always used. Fine! If they like a power brush, then that is great! Just make sure the head is replaced at least every 3 months. Do they prefer a manual brush? Make sure it is a brush with a small head, large handle and SOFT bristles. They also need replacing at least every 3 months.
If the patient has dementia, they may not be able to tolerate a power toothbrush. The power brush may make them think there is a bee inside their mouth! You can either use a soft-bristled brush that you and the patient like, or use the 3-D brush: the Benefit 3-D Benedent toothbrush.
These toothbrushes have 3 sides and have a perfect angle to the gumline for the inside, the cheek-side, and the chewing side of the teeth. The bristles are soft and flexible and are comfortable for even fragile tissues. The large handle makes it easy for a caregiver to hold. Due to the unique use of the brush though, I don’t recommend the patient brush their own teeth with this 3-D brush unless you can see they use it correctly. The caregiver gently presses the brush head down onto the teeth so all sides are in contact with the bristles as in the picture.
Interdental cleaning “Flossing”: There are numerous products to clean between the teeth, floss being only one of them. Here are samples of floss alternative products I like.
Pictured: Reach Access Flosser, GUM Soft-Picks, Sulcabrush, GUM rubber tip Stimulator, and Water Pik oral irrigator.
Mouthwash: Use a mild, non-alcoholic, non-burning antiseptic mouthwash. Good examples are Biotene and Closys rinse.
Toothpaste: This can be either a fluoride toothpaste with a mild flavor (many older adults do not like the strong taste of mint -try a children’s flavor if they like) OR they can use a prescription strength toothpaste you can obtain from your dentist or hygienist. You only need a little bit- a small pea-sized amount.
Other great products: Xylitol and oral moisturizers: Use a spray xylitol (I like RAIN by Spry) and spritz ~3 times several times a day throughout the day to fight cavities and gum disease. Patients often also have dry mouth and you can alternate this with Biotene oral moisturizer spray (liquid or gel) as well. Use these either after snacks or after the patient uses the toilet for you to remember.
If the patient can brush their own teeth:
Make sure they have the tools they need to do the job. Do they like a power toothbrush? Make sure the head is replaced at least every 3 months. Do they prefer a manual brush? Make sure it is a brush with a small head, large handle and SOFT bristles and replaced every 3 months.
Is flossing becoming more difficult? There are several “floss alternatives” out there that I like, again, depending on the patient. For someone who is still somewhat independent, they may be able to handle a water irrigator (Water Pik) which is easier than a string of floss, or they may like a flosser with a long handle such as the Reach Access Flosser, -no need to hold the string or put hands in the mouth, and GUM Soft Picks are easier to use (and more gentle) than toothpicks. If dexterity is an issue, the Sulcabrush wins, hands down, and cleans not only between teeth, but around crowns, implants and under bridges.
As a caregiver, you will need to check how your patient does on their own by occasionally inspecting their mouth and teeth. If you see a decline in their own care, you will need to provide additional care.
One method of care is called guidance: You may need to prompt someone at each step along the way. Are they forgetting to brush? Get their supplies out for them and remind them. Are they forgetting to use the toothpaste? Are they only brushing their front teeth? Or maybe only brushing one side? You can help by prompting and reminding them.
Hand over hand guidance: If they still are missing areas, even with prompts, you can gently place your hand on top of their hand and help guide their hand to the area missed.
If they are able to brush, but not clean between their teeth, you can use the Sulcabrush too to get some of the nooks and crannies that were missed. It is easy for both patient AND caregiver to handle and deliver oral interdental care. (And no hands between teeth!) See below for great pictures of how to use the brush:
For the Co-operative and Dependent Adult:
For an adult who is cooperative, but who is unable to brush, just follow these steps:
Assuming your patient is not in the bathroom next to the sink:
1. Have the patient sit up, either in bed, in a chair, or in a wheelchair.
2. Get out all your supplies you will need (brush, paste, cup of water, interdental cleaning device/floss, cup with mouth wash, clean disposable gloves, small towel and a kidney basin). Optional: small flashlight.
3. Put on your clean disposable gloves.
4. Sit or kneel in front of your patient at eye level. Do not hover over them.
5. Ask the patient to rinse their mouth with water, if they are able to swish and rinse. If not, they may be able to rinse and swallow. Do not use this step if they might choke!
6. Check the inside of the cheeks for food debris. Use a gloved finger wrapped in gauze to remove, or a tooth swab.
7. Now INSPECT the mouth: Look at the lips, cheeks, the tongue, the palate, and the teeth.
8. If there are any broken teeth, areas of decay or abscesses or if you notice any cracking, lumps, white or red lesions, or sores that do not heal within 2 weeks, you should consult a dentist or doctor.
9. Dip the toothbrush in a mouthwash, shake, and use the brush to clean the mouth of major food particles first.
10. Once the mouth is clear of major particles, place a small, pea-sized amount of toothpaste on the brush and brush gently. Gums are more fragile in older people so go slow and steady! Brush each tooth with a small circular motion and gentle pressure. If using a traditional brush, angle the brush towards the gums as you brush the outside, inside, and chewing surface of each tooth. Optimal is to brush for two minutes, twice a day.
11. Rinse with water or have patient sip water if possible.
12. Gently brush the tongue, start at the middle back and stroke forward.
13. Cleaning between the teeth: Use the Sulcabrush (pictures above) to brush between the teeth, or use Soft Piks or other flosser to clean between the teeth.
14. If patient is able, have them rinse with a mild mouthwash such as Biotene or Closys. If they are likely to swallow or choke, omit this step.
Dentures must be removed daily and soak for at least 4 hours a day. The tissues of the mouth need to breath and recover from the dentures at least 4 hours a day. Best time to do this is at night. Dentures are VERY fragile and can break if you drop them in the sink, so line the sink with 2 layers of paper towels. Do not use regular toothpaste as it is too abrasive. Brush the dentures and soak in either plain water (changed daily!) or in a denture soak such as Polident.
INSPECT the mouth: Look at the lips, cheeks, the tongue, the palate, and the teeth. If there are any broken teeth, areas of decay or abscesses or if you notice any cracking, lumps, white or red lesions, or sores that do not heal within 2 weeks, you should consult a dentist or doctor.
Brush the gums with a gentle, soft bristle toothbrush.
After meals or snacks:
If safe, ask the patient to rinse, spit or swallow a cup of plain water (they can spit back into the cup). Frequent sips of water throughout the day will help cleanse the mouth.
Xylitol and oral moisturizers: Use a spray xylitol (I like RAIN by Spry) and spritz ~3 times several times a day throughout the day to fight cavities and gum disease. Patients often also have dry mouth and you can alternate this with Biotene oral moisturizer spray as well. Use these either after snacks or after the patient uses the toilet for you to remember.
For the RESISTANT and Dependent Adult:
This is the tougher task, no doubt about it. Here is a list of tips and tricks to make this easier.
1. Try to know the reason behind the resistance. Remember that for a dementia patient the only way they can communicate is through behavior. Are they in pain? Is it a bad time for them? Are they tired? Are they afraid?
2. If they are in pain, EVERYTHING will be more difficult! Make sure they are not in pain, make sure they don’t have broken teeth, abscessed teeth, infection or other problem.
3. Always approach from the front. Dementia patients have difficulty seeing to the side of them. They have “tunnel vision” and you can startle them from the side.
4. Smile! Introduce yourself! Put your hand out and hold their hand. This reassures them and helps gain trust.
5. Complement them. Tell them they have beautiful teeth and you are there to keep them beautiful.
6. Tell them you will make their mouth more comfortable. You are there to get that food out from between their teeth.
7. Focus on the person, not the task.
8. Explain each step.
9. Be patient and repeat.
10. Give positive feedback and encouragement. ALWAYS say “Thank you” when they open their mouth.
11. Try singing, music that they like and is calming, say silly things, tell a joke, try gentle laughing. Remember when they sing, they open their mouth. When they laugh, they open their mouth! Tell them “thank you” every time they make your job easier!
12. Give them a stuffed animal to hold (or a doll, blanket, pillow, etc.) to comfort them.
13. Phase in oral care. Start with just clearing the mouth of debris and work your way up.
14. Tap the lower lip with the brush to prompt opening the mouth.
15. Massage the jaw and jaw joint.
16. If they grab at your arm or brush, hand them the brush and invite them to brush.
17. Come back at another time. Pick another time of day. Maybe morning, maybe evening.
18. Slide your finger inside the cheek (but NOT between the teeth!).
19. If they bite the brush, just be patient and gently wiggle the brush.
20. Have another caregiver hold their hands to reassure them.
21. Change the flavor of the products. Many older folks don’t like the strong flavor of mint.
22. Try a different toothbrush. Soft and small!
23. Never use a mouth prop to force the mouth open. It just doesn’t work. Props are only for people who want to “rest their teeth and jaw”. Otherwise it feels like handcuffs.
24. Establish a routine. The more this is done, the more familiar it is.
Professional Dental Care:
Have a mobile hygienist come visit at least twice a year. The hygienist may recommend three or four cleanings a year, depending on the patient.
At least ONCE a year (and more often if there are problems) the patient should see a dentist. Ask the hygienist for a referral. Even those that only wear dentures need an annual exam.
Ann Ossinger is a Registered Dental Hygienist who owns DoorStep DentalHygiene, LLC, a mobile dental hygiene service that provides dental hygiene services to people who would otherwise be unable to go to a regular dental clinic in the Linn-Benton Counties of Oregon. 541-990-0814. Please contact Ann if you have any questions!