Supporting someone with dementia in maintaining their oral health can be one of the more challenging aspects of your role as a carer. Individuals may push your hand away, clamp their mouths shut, or become distressed when you're simply trying to help.

It’s essential to remember that this behaviour is not about the person being difficult. 

Dementia changes the brain in ways that make oral care genuinely more challenging. They may not remember what a toothbrush is for, find the bristles overwhelming, or be unable to communicate that something hurts.

The good news is that with the right understanding, patience, and self-care strategies, mouth care can become calmer and more manageable for everyone involved. If you're feeling overwhelmed or unsure of how to adapt when someone cannot cooperate, this guide is here to help.

Why Dementia Affects Mouth Care

Providing mouth care for someone with dementia can be particularly challenging. If you've experienced someone pushing your hand away, clamping their mouth shut, or becoming upset, know that you’re not alone. 

This isn't about the individual being difficult. It's important to recognise that dementia alters the brain in ways that complicate oral hygiene. Here are some of the key reasons:

Memory: They may forget to brush their teeth each morning, may not remember that they brushed yesterday, or might not understand the purpose of a toothbrush.

Sequencing: Executing tasks that we perform automatically, such as picking up the toothbrush, applying toothpaste, and using the brush, can be challenging to coordinate.

Recognition: Familiar objects may appear unfamiliar. For example, a toothbrush may not be recognised as a helpful tool.

Sensation: The feeling of bristles, the taste of toothpaste, or having someone’s hands near their face may seem strange, unexpected, or even threatening.

Communication: They may struggle to express that something hurts, that the toothpaste tastes wrong, or that they feel scared.

Understanding these challenges can help you adapt your approach. By recognising why something is difficult for the individual, you can implement proper techniques to make mouth care calmer and more comfortable for everyone involved.¹

Understanding Resistance

When a person living with dementia resists mouth care, they are trying to communicate something important.² It's crucial to recognise that this resistance is not a sign of defiance. It is a form of communication,

What Resistance Might Be Telling You

Pain or Discomfort: Issues like a sore tooth, tender gums, or poorly fitting dentures can make mouth care painful. Although they may find it difficult to articulate this verbally, pulling away sends a clear signal of their discomfort.

Fear or Anxiety: Having someone place an object in their mouth can feel invasive and threatening, especially if they don't fully understand what is happening.

Sensory Overwhelm: The taste, texture, temperature, or smell of dental products might be overwhelming. For example, the flavour of mint toothpaste can be unexpectedly strong.

Lack of Understanding: If they do not recognise the toothbrush or grasp what you are asking, the entire situation can become confusing.

Loss of Control: If mouth care feels like something being done to them rather than with them, it may feel disempowering. Resistance can serve as a way for them to assert some control over the situation.

Past Experiences: Previous negative dental or care experiences may trigger anxiety during mouth care.

Look for Patterns

Observe when resistance occurs. 

Is it more common at specific times of day, with certain individuals, after particular activities, or in specific locations? 

Identifying these patterns can provide valuable insight. For instance, someone might resist during a hectic morning routine but be calmer after breakfast, or they may respond better to one caregiver than to another.

It's Not Personal

When someone pushes your hand away or turns their head, it can feel like a personal rejection. It's important to remember that this response is based on their feelings about the situation at that moment and not a reflection of their feelings towards you as an individual.

Three Levels of Support

People living with dementia require varying levels of support, which can change over time.³ It's important to recognise that adapting these support levels is manageable and can help staff feel capable and confident in their care.

On challenging days, an individual may need more assistance, while on better days, they may need less. It's best to start with the least amount of support necessary and increase it if needed.

Level 1: Prompting

At this level, the individual can still brush their own teeth with reminders and encouragement.  

What you do:

• Provide a gentle verbal reminder: "It's time to brush your teeth now."
• Hand them their toothbrush, already prepared with toothpaste.
• Point to the basin or mirror to help orient them.
• Stay nearby and offer encouragement.
• Give straightforward instructions one step at a time, such as: "Put the brush in your mouth," and wait. Then say, "Move it around your teeth."

When it works: This level is adequate during the earlier stages of dementia or on good days when the person is calm and alert.

Level 2: Guiding

At this level, the individual needs physical guidance to complete the task. They remain involved, but you assist them through the movements.  

What you do:

• Place your hand gently over theirs on the toothbrush.
• Guide the brushing movement together.
• Allow them to feel that they are participating with your support.
• Break the task into small steps, pausing between each one.
• Use hand-over-hand guidance only as needed.

When it works: This level is suitable when verbal prompts alone are insufficient, but the person can still participate physically.

Level 3: Assisted Care

At this level, you provide mouth care while keeping the person as comfortable and engaged as possible.  

What you do:

• Calmly explain what you are going to do, even if you’re unsure they understand. Your tone is essential.
• Position yourself where they can see you; standing behind someone can feel threatening.
• Use gentle, slow movements.
• Provide something for them to hold, such as a second toothbrush, to make them feel involved.
• Observe their facial expressions and body language for any signs of discomfort.
• If they show signs of distress, pause and try again later or use a different approach.

When it works: This level is appropriate during the later stages of dementia or when the individual cannot participate physically.

Practical Strategies That Help

These techniques have been developed by caregivers who have identified what works best for individuals.4 It's important to remember that not every strategy suits everyone, so trying different approaches can help determine what is most effective.

Timing

• Choose a calm moment for care. Rushing can increase anxiety for everyone involved.
• If mornings are challenging, consider starting after breakfast when the person has settled. Some individuals may be more relaxed in the evening.
• If a particular time consistently doesn’t work, try a different time.

Environment

• Ensure good lighting to enhance visibility and help the person feel more oriented.
• Reduce distractions by turning off the television and closing the door if there is outside noise.
• A familiar bathroom is preferable to an unfamiliar one. If the person has recently moved to a care home, mouth care may become more challenging as they adjust to their new surroundings.
• Make sure they are comfortable; sitting tends to be better than standing.

Your Approach

• Maintain a calm demeanour, as your mood can influence theirs. They will sense any tension or urgency.5
• Smile to provide reassurance; a warm expression makes a difference.
• Make eye contact and lower yourself to their level, rather than looming over them.
• Use simple language with short sentences, focusing on one idea at a time. For instance, say "Open your mouth" instead of "Can you open your mouth so I can brush your teeth for you?"
• Avoid arguing or correcting them. If they say they’ve already brushed their teeth, gently redirect the conversation with "Let's just freshen up."
• Use their name to help with attention and connection.

Technique Adaptations

• Allow them to hold a toothbrush, even if they’re not actively brushing. This involvement can help them feel more engaged rather than passive.
• Use familiar products. If they have always used a particular toothpaste, continue with that to avoid resistance due to unfamiliar tastes.
• Consider using a smaller brush. A child’s toothbrush or one with a smaller head may feel less intrusive.
• Try an electric toothbrush. Some people find the vibration soothing, while others may find it distressing. Experiment to see what works best for the individual.
• Sing or hum a familiar tune. This can be calming and help with timing, signalling that this is a routine rather than a threat.
• Use the mirror technique: stand beside them and brush your own teeth. They may instinctively imitate your actions. This method relies on procedural memory, which often remains intact longer than other types of memory.

When Resistance Happens

1. Pause. Stop what you're doing and take a deep breath.
2. Reassure them with a calm voice, saying, "It's alright. We can stop for a moment."
3. Give them space. Step back slightly to ease the tension.
4. Try again. After a minute or two, attempt a different approach, such as changing position, using a different toothbrush, or applying a gentler touch.
5. Know when to stop. If it’s not working that day, consider focusing on a later time or trying again in the evening. Forcing mouth care can lead to distress and make future attempts more difficult.

Remember that “good enough, often enough,” is the goal. Perfection isn't required. Instead, consistency over time is more important than getting it exactly right every single day. 

Denture Care Reminders

If the person wears dentures, it is important to remain calm, patient, and adaptable to their needs. 

Partial dentures: 

• Remember that individuals with partial dentures still have natural teeth that need to be brushed with fluoride toothpaste (1,350–1,500ppm fluoride, commonly 1450ppm), just as anyone else's do. 
• Clean the partial denture separately, and do not neglect the natural teeth.

Full dentures: 

• Clean twice daily. 
• Remove overnight and store in a labelled pot with water.

Detailed guidance: 

• For the full step-by-step process, refer to the guide "Daily Mouth Care Routines for Carers." 
• This companion guide includes details on denture removal, cleaning, storage, and the necessary equipment.

As Dementia Progresses

Dementia is a progressive condition. A person who managed with prompting six months ago may now require full assistance. This is not a sign of failure. Instead, it is a natural progression of the illness. 

In this case, you need to adapt to the individual's changing needs. What worked before may not work now, so remain flexible and keep exploring different approaches.

Dry Mouth

Dry mouth is common in people with dementia, particularly in the later stages. Causes can include medications, mouth breathing, and reduced fluid intake. 

A dry mouth is uncomfortable and increases the risk of oral infections, soreness, and difficulty swallowing.¹

For detailed guidance on managing dry mouth, see the resource "Mouth Care at End of Life," which covers this topic in depth.

Signs That Need Dental Attention

Contact a dentist or speak to a senior colleague if you notice any of the following:

• Signs of pain, such as pulling away, facial grimacing, or refusing to eat
• Red, swollen, or bleeding gums
• Loose or broken teeth
• White patches or ulcers
• Dentures that no longer fit properly
• Difficulty eating or changes in eating habits
• Persistent bad breath that does not improve with regular mouth care

Accessing Dental Care

Many individuals living with dementia can visit a general dental practice, especially in the earlier stages, where familiar faces and routines can provide comfort.6 

For those who cannot travel, Community Dental Services may offer at-home visits. Check with your manager about available options in your area. 

For urgent issues, you can call NHS 111 for guidance and to be directed to emergency care.

Quick Reference

Remember:

• Resistance is communication, not defiance
• Start with the least support needed
• Choose calm moments
• Use simple words, one instruction at a time
• Let them stay involved where possible
• Pause if resistance happens
• Good enough, often enough

Three levels of support:

• Prompting: Reminders and encouragement
• Guiding: Hand-over-hand support
• Assisted: You provide the care

Strategies to try:

• Mirror technique: brush your teeth alongside them
• Let them hold a toothbrush
• Sing or hum familiar tunes
• Try different times of day
• Use familiar products

Partial dentures: Natural teeth still need to be brushed. See Daily Mouth Care Routines for Carers for complete guidance.

When to Get Help

Signs of mouth problems:

• Facial grimacing or signs of pain
• Refusing food or changes in eating
• Red, swollen, or bleeding gums
• Loose or broken teeth
• Dentures are causing sore areas
• White patches or ulcers lasting more than two weeks

If mouth care is consistently very difficult:

• Speak to colleagues who know the person well
• Ask if there could be an underlying cause, such as pain
• Consider a dental assessment to rule out problems
• Review medications that might cause dry mouth

Dental access:

• General dental practices for those who can travel
• Community Dental Services may be able to provide domiciliary visits, depending on local availability.⁶
• NHS 111 for urgent advice