Oral Care for People With Dementia: A Caregiver’s Guide

Helping someone with Alzheimer’s disease or another form of dementia care for their mouth can become increasingly difficult.

A person who brushed independently for decades may gradually:

• forget whether they brushed
• forget what a toothbrush is for
• have trouble following several steps
• lose the hand coordination needed to brush well
• become frightened when someone approaches their mouth
• resist help they do not understand
• have trouble describing tooth or denture pain

The goal is not simply to “get the brushing done.”

A better goal is to protect the person’s teeth, gums, comfort, nutrition and dignity while helping them remain as independent as possible.

As dementia progresses, the caregiver may need to move gradually from reminding, to demonstrating, to guiding, and eventually to providing more of the oral care directly.

Why Oral Care Becomes Harder With Dementia

Dementia can affect:

• memory
• sequencing
• judgment
• communication
• coordination
• recognition of familiar objects
• ability to describe pain

A person may hold a toothbrush but no longer remember what comes next.

Another person may understand the task but have difficulty moving the brush effectively.

Later, someone may not understand why another person is putting an object into their mouth.

These are changes caused by the disease.

They should not automatically be interpreted as stubbornness.

Keep the Person Involved as Long as Possible

Do not take over a task simply because it takes longer.

If the person can still brush independently with a reminder, let them.

As more help becomes necessary, try progressing through these levels:

Level 1: Reminder

Say:

“It’s time to brush your teeth.”

Level 2: Set Everything Out

Place the toothbrush and toothpaste where they can see them.

Level 3: One Step at a Time

Instead of saying:

“Brush your teeth.”

try:

• “Pick up your toothbrush.”
• “Put toothpaste on it.”
• “Put the brush in your mouth.”
• “Brush these teeth.”
• “Now brush the other side.”

Level 4: Demonstrate

Brush your own teeth where the person can see you.

They may be able to copy your movements.

Level 5: Hand-Over-Hand Help

Place your hand gently over theirs and guide the brushing motion.

Level 6: Provide the Care

Eventually, the caregiver may need to do most or all of the brushing.

The level of help may vary from one day to another.

Keep the Routine Familiar

People with dementia often do better with predictable routines.

Try to use:

• the same location
• the same toothbrush
• the same toothpaste
• the same sequence
• roughly the same times each day

If the person has always brushed at the kitchen sink rather than the bathroom, there may be no need to change that.

The best location is often the place where the person feels calm and comfortable.

Choose the Best Time of Day

Many people with dementia have times when they are:

• calmer
• more alert
• more cooperative

If evenings are consistently difficult, consider doing the more thorough cleaning earlier while still making sure the teeth are cleaned after the day’s final food or medication when practical.

Do not insist on an exact clock time if another time works much better.

Prepare Before You Begin

Gather everything first.

You may need:

• soft-bristled toothbrush
• fluoride toothpaste
• cup or basin if appropriate
• towel
• interdental brush or floss holder
• denture brush
• denture container
• denture cleanser when used
• disposable gloves if you prefer them
• flashlight if visibility is poor

Having to walk away repeatedly can disrupt the routine.

Position the Person Comfortably

Have the person sit upright in a stable chair if possible.

You may find it easier to stand:

• slightly behind them
• beside them

rather than directly in front of them.

Make sure you can see into the mouth without forcing the person’s head backward.

A towel across the chest can help with drips.

Brush Twice Daily When Possible

For natural teeth, aim for brushing twice a day with fluoride toothpaste.

Use a soft-bristled toothbrush.

Clean:

• outer surfaces
• inner surfaces
• chewing surfaces
• along the gumline

Brush gently.

Aggressive scrubbing is not necessary and may be uncomfortable around exposed roots or receding gums.

Use a Familiar Toothbrush

An electric toothbrush can help some people.

It may be easier to hold and does much of the brushing motion.

But for someone with dementia, the vibration and sound may be confusing or frightening.

If an electric toothbrush causes distress, a simple manual brush may work better.

There is no requirement that the most technologically advanced toothbrush be used.

The best brush is one the person will tolerate and that allows the teeth to be cleaned effectively.

Try the Tell-Show-Do Approach

Before touching the person’s mouth:

Tell:
“I’m going to help clean your teeth.”

Show:
Let them see the toothbrush.

You can demonstrate the movement.

Do:
Begin gently and predictably.

Continue explaining in short phrases:

• “I’m brushing this side.”
• “Now the front.”
• “Almost finished.”

Avoid long explanations while the brushing is underway.

What If the Person Refuses?

Do not turn oral care into a physical struggle.

If the person:

• pulls away
• closes the mouth tightly
• becomes frightened
• pushes your hand away
• becomes increasingly distressed

stop.

Try to determine why.

Possible explanations include:

• fear
• confusion
• pain
• fatigue
• an unfamiliar caregiver
• an uncomfortable toothbrush
• too much noise
• being rushed

Try again later when possible.

A different time, location, toothbrush or caregiver may work better.

Do Not Force the Mouth Open

Do not pry the person’s jaws apart or try to force a toothbrush into a tightly closed mouth.

If they clamp down on the toothbrush, avoid pulling against the teeth.

Wait calmly for the jaw to relax.

Repeated inability to provide oral care is a reason to discuss techniques with the person’s dentist or hygienist.

Pain May Look Like “Behavior”

Someone with dementia may not be able to say:

“My lower molar hurts.”

Possible signs of oral discomfort include:

• refusing certain foods
• chewing on one side
• grimacing while eating
• pulling away during brushing
• touching the face or mouth
• refusing dentures
• suddenly leaving dentures out
• unexplained irritability during meals
• swelling
• bad breath
• drooling
• disturbed sleep

These signs are not proof of dental pain, but they deserve attention.

A sudden major change in behavior can have many medical causes and should not automatically be blamed on dementia or the teeth.

Look Into the Mouth Regularly

When the person is calm, check for obvious changes such as:

• broken teeth
• swollen gums
• persistent bleeding
• sores
• white or red patches
• swelling
• loose teeth
• denture irritation
• food trapped around teeth or appliances

You do not need to perform a dental examination.

The goal is to notice changes that should be reported.

Clean Between the Teeth When Practical

Interdental cleaning helps remove plaque that brushing does not reach.

Options may include:

• floss
• floss holders
• interdental brushes
• other devices recommended by the dentist

Traditional string floss may be unrealistic if the person cannot cooperate or the caregiver finds it difficult.

Ask the dental hygienist to show you the simplest method for that person’s mouth.

Consistency and safety are more important than using a particular device.

Water Flossers May Work for Some People

A water flosser can be useful around:

• natural teeth
• bridges
• implants

But it requires the person to tolerate water in the mouth and cooperate with the device.

It may not be suitable when swallowing is impaired or the person cannot manage the water safely.

Ask the dental team if you are uncertain.

Swallowing Problems Need Extra Caution

Some people with advanced dementia develop difficulty swallowing.

If this happens, do not automatically hand the person a cup of water and tell them to rinse.

They may not be able to control the liquid safely.

Instead:

• keep the person upright
• use only the amount of toothpaste and liquid they can manage safely
• wipe excess material from the mouth when needed
• ask the dentist or healthcare team how to adapt the routine

If swallowing problems are new or worsening, they deserve medical assessment.

If the Person Cannot Spit Reliably

Tell the dentist.

The dental team can help determine:

• the most appropriate toothpaste amount
• whether rinsing should be avoided
• how to manage fluoride safely
• whether additional professional fluoride is needed

Do not abandon fluoride protection merely because the normal brushing routine has become difficult.

Dry Mouth Is Common and Important

Dry mouth can increase the risk of:

• cavities
• root decay
• oral soreness
• difficulty swallowing
• denture discomfort

Medications are a common contributor.

Other medical conditions may also be involved.

Look for:

• frequent complaints of dryness
• thick or stringy saliva
• cracked lips
• difficulty eating dry foods
• frequent sipping during meals
• increasing cavities

Do not stop prescription medicines on your own.

Discuss persistent dry mouth with the dentist and prescriber.

Protect Against Cavities

A person with dementia may become increasingly dependent on:

• caregivers
• prepared foods
• snacks
• liquid medications

Frequent exposure to sugar can raise cavity risk.

Helpful steps include:

• fluoride toothpaste
• regular cleaning
• water between meals when swallowing is safe
• limiting repeated sugary snacks and drinks
• additional fluoride when the dentist recommends it

The priority is not creating a restrictive diet.

It is reducing unnecessary repeated sugar exposure while maintaining adequate nutrition.

Denture Care Is Still Daily Care

If the person wears removable dentures:

• remove them daily
• rinse away loose debris
• brush them with a denture brush
• use a nonabrasive denture-cleaning product
• clean the gums, tongue and other oral tissues
• remove dentures at night unless the dentist has given a different instruction
• store them according to the dentist’s and product manufacturer’s instructions

Do not use ordinary abrasive toothpaste on dentures.

Do not use very hot water, which can distort some denture materials.

Watch for Denture Problems

Have the dentures checked if you notice:

• repeated sores
• redness underneath them
• frequent slipping
• clicking
• difficulty chewing
• refusal to wear them
• cracks or broken teeth in the denture
• unexplained weight loss associated with difficulty eating

A person who suddenly refuses a familiar denture may be communicating discomfort.

Dental Implants Still Need Cleaning

Implants do not get cavities, but the tissues around them can become inflamed.

Implant crowns, bridges and overdenture attachments also collect plaque.

Ask the dental team to demonstrate the easiest cleaning method.

Depending on the restoration, this may involve:

• toothbrush
• interdental brush
• floss threader
• water flosser
• other specialized tools

As dementia progresses, simpler methods may be better than technically ideal methods that cannot be performed consistently.

Keep Dental Visits Going as Long as Practical

Routine dental care can become more difficult as dementia progresses.

But postponing all dental care until there is severe pain can lead to more complicated treatment.

Tell the dental office about the dementia diagnosis when scheduling.

Useful information includes:

• level of communication
• what helps the person stay calm
• best time of day
• mobility needs
• medications
• whether a caregiver needs to remain in the room

A familiar caregiver may provide reassurance during the visit.

Dental Appointments May Need to Be Simpler

People with dementia may do better with:

• shorter appointments
• quieter surroundings
• fewer people in the room
• simple instructions
• familiar caregivers
• morning appointments if that is their best time

Treatment priorities may also change as dementia progresses.

The goal is usually to:

• prevent pain
• control infection
• preserve comfortable function
• avoid unnecessarily complicated treatment

Dementia Does Not Automatically Remove the Person From Decisions

Continue to speak to the person, not just about them.

Explain what is happening in simple language.

Offer reasonable choices when possible.

Respect:

• privacy
• preferences
• familiar routines
• signs of distress

The person’s ability to participate may change over time, but dignity should not.

Make a Simple Mouth-Care Plan

A written caregiver plan can include:

Natural teeth:
Which teeth remain and how they are cleaned.

Dentures:
Full, partial or none; where they are stored.

Implants or bridges:
Special cleaning needs.

Toothpaste:
Preferred fluoride toothpaste.

Dry mouth:
Products or strategies being used.

Best time:
When oral care is usually easiest.

Helpful approach:
For example, “Let her hold the brush first.”

Warning signs:
What the dentist wants the caregiver to watch for.

This can be especially useful when several family members or professional caregivers provide care.