As a dental hygienist, I am always concerned about the dental health of my senior patients. The elderly often have problems with manual dexterity, dry mouth (xerostomia), and often have a high rate of decay (cavities). In order to combat these concerns, seniors should continue brushing and flossing daily, just as they did when they were younger. But what if the senior is having a hard time remembering to brush or isn’t able to brush effectively due to manual or cognitive impairment?
In these cases, here’s how to help elderly brush their teeth:
- Set reminders for brushing on the senior’s phone or with a virtual assistant like the Echo or Google Home
- Floss the teeth, under bridges, and around implants or use a water flosser
- Use an electric toothbrush with a timer or brush with a manual toothbrush for two minutes
- Brush with a fluoridated toothpaste, especially if the senior has a dry mouth
- Clean dentures and partials daily and always remove them at night. Soak them in a cleaning solution overnight.
- If a caregiver is brushing the person’s teeth, they should wear clean disposable gloves to avoid spreading germs
- The senior should visit their dentist at least twice a year – even if they have no teeth at all
I always recommend using a fluoridated toothpaste, especially if the elder has a dry mouth (xerostomia). Fluoride helps to reduce cavities, which can be a big issue in people with xerostomia because their saliva flow has decreased. Since saliva naturally “rinses” the teeth and helps to lessen decay-causing bacteria in the mouth, if saliva flow is reduced or impaired, the bad bacteria gain a foothold and attack soft tooth roots and tooth surfaces. I have seen senior patients lose so many teeth to decay in a short period of time that they have to go into dentures (which can have their own issues).
Additionally, if the senior has a dry mouth and sucks on candy or chews gum to help moisten it, the candy or gum should only be sugar free. Again, that impaired saliva flow is not rinsing off the sugars, so the acids from the candy sit on the teeth and can easily cause rampant decay. Look for products that contain xylitol, which is a natural sweetener that helps to prevent cavities.
Xylitol tastes sweet but, unlike sugar, it is not converted in the mouth to acids that cause tooth decay. It reduces levels of decay-causing bacteria in saliva and also acts against some bacteria that cause ear infections. – WebMD
*Note: WebMD also cautions that, “Dog owners should know that xylitol can be toxic to dogs, even when the relatively small amounts from candies are eaten. If your dog eats a product that contains xylitol, it is important to take the dog to a veterinarian immediately.”
Why Is Oral Care Important In The Elderly?
Oral care is extremely important, particularly for the elderly. Aside from making day to day life more miserable, tooth loss and cavities can severely and adversely impact physical health, especially in frail seniors.
- Periodontal (gum) disease carries a higher risk of stroke and heart disease, says the American Academy of Periodontology.
- The American Academy of Periodontology also reports that recently, scientists “uncovered a potential link between P. gingivalis, the bacteria associated with periodontal disease (commonly known as gum disease) and Alzheimer’s.”
- We’ve known for decades that heart conditions can be worse when people don’t take care of their oral health. Over my thirty-plus years in dentistry, I have seen many patients who came in to the office because their cardiologist “made me”. In fact, the American Dental Association (ADA) reports that, “Several studies link chronic inflammation from periodontitis with the development of cardiovascular problems. Some evidence suggests that oral bacteria may be linked to heart disease, arterial blockages and stroke.”
- “There is a strong link between tooth loss and malnutrition,” says AARP. “Among older patients who received treatment at the Rutgers School of Dental Medicine clinic, more than 25 percent showed signs of malnutrition or were at risk for malnutrition.”
- “Some studies suggest that periodontitis can make it more difficult for people with diabetes to control their blood sugar,” says the American Dental Association (ADA).
- The Mayo Clinic reports that, “Certain bacteria in your mouth can be pulled into your lungs, causing pneumonia and other respiratory diseases.” This is often seen in seniors who are in nursing homes or who have caregivers who aren’t aware of the need for good oral hygiene.
How To Brush Elderly Teeth
Here are this dental hygienist’s step by step guidelines for how to brush elderly teeth:
- Before beginning, set a chair by the sink so your loved one can sit down. This will make it easier for you to see into their mouth without hurting your neck.
- Also have a towel, the toothbrush, floss, an empty cup, and the toothpaste next to the sink.
- Drape a towel over their chest and tuck it into their neckline.
- Put on clean disposable gloves to keep you both from transferring bacteria and germs to each other.
- Stand behind the person and cradle their head against your body to hold them steady while you are brushing and flossing their teeth.
- Ask them if anything hurts in their mouth. Check the inside of their mouth for any sores, lumps or “blisters”, and cracking or cuts in the lips or tongue. If you see anything, write down what it looks like and the date you saw it – if the area has not gone away within two weeks, please consult a dentist.
- *Floss their teeth and under any bridges (see Tip below).
- Using a soft bristle toothbrush (or an electric toothbrush, which is my personal recommendation), gently brush all tooth surfaces – the outside, inside, and chewing surface of each tooth.
- Brush for two minutes, tilting the brush toward the gums (you need to brush their gums, too) and moving in small circles (here’s where an electric brush would do the work for you).
- Also, gently brush the person’s tongue and the roof of their mouth, if you can.
- Have the senior spit out the toothpaste and rinse their mouth. If they are unable to rinse, have them spit out as much toothpaste as they can. It is all right to have a small amount of toothpaste remaining in their mouth afterwards, but they shouldn’t swallow a mouthful of toothpaste (the fluoride in it can upset the stomach).
- If the senior wants to use mouthwash (and can do so without choking), it should be an alcohol-free mouthwash, and preferably one that contains fluoride.
*TIP: Take it from someone who does it many times a day – it is tricky to floss someone else’s teeth and under most bridges. If there is enough space between the teeth, try using a proxabrush instead of floss. These are tiny tufted brushes, sort of like a pipe cleaner. They come in a couple of different sizes and you can find them online or at the drug store or grocery store.
If the person does not have swallowing or choking issues and can bend over the sink, you could try a water flosser to make flossing less challenging. Just know that they are really messy and you both should tuck a towel into your neckline to avoid getting too wet.
How To Brush The Teeth Of A Bedridden Patient Who Is Alert
If you are a caregiver who is helping a loved one while they are in a hospital bed (or who may be confined to their own bed for some reason), you’ll need to know how to brush the teeth of a bedridden patient.
NOTE: the following process is only for bedridden people WHO ARE ALERT!
- Assemble everything you need on a tray or on a bedside table. You’ll need disposable gloves, two towels, the toothbrush, floss, an empty bowl, a cup of water plus another empty cup, and the toothpaste. Lip balm might also come in handy if their lips are dry.
- Raise the bed into an upright position, if possible, or have the person sit up in the bed.
- Stand in front of the senior, slightly to one side
- Drape one towel over the person’s chest. Have the other towel close by to wipe up any drool or saliva.
- Put on a clean pair of disposable gloves so you don’t spread germs and bacteria to each other.
- Ask the person if they are having any mouth pain. Check the inside of their mouth for any sores, lumps or “blisters”, and cracking or cuts in the lips or tongue. If you find something, write down what it looks like and the date you saw it – if the area has not gone away within two weeks, please consult a dentist.
- If possible, floss their teeth and under any bridges before brushing.
- Dip the toothbrush in the cup of water to moisten it, then apply a small, pea-sized bead of toothpaste to the brush. (Hint: electric toothbrushes basically do the work for you and they remove more plaque – I highly recommend them).
- Gently brush all tooth surfaces – the outside, inside, and chewing surface of each tooth – for two minutes. Tilt the brush toward the gums so that you are brushing the gum line. Move in small circles (here’s where an electric brush would do the work for you).
- Also, gently brush the person’s tongue and the roof of their mouth if you can.
- Have the person rinse out the toothpaste with the water in one cup. They will swish first, and then spit it out into the second, empty cup. Swishing with an alcohol-free mouthwash that contains fluoride is a good option, too.
- Apply lip balm to keep the person’s lips from drying and cracking.
- Rinse the toothbrush and cups and stand the toothbrush up in one cup (bristles up) to dry.
For a senior who is unconscious, you would need to use additional items, such as a bite block to hold their mouth open. There is a high chance of choking, not to mention of you getting bitten (not fun when a person unknowingly clamps down on your finger). You should not use toothpaste on someone who is unconscious because they could aspirate it into their lungs or choke on it – a disposable swab or sponge toothbrush is a better choice.
For these reasons, I really don’t recommend that a caregiver try to brush the teeth of an unconscious loved one. Instead, if you have a licensed caregiver coming in (or if the person is in the hospital), have the other caregiver or the nursing staff brush the person’s teeth.
How Do You Get A Dementia Patient To Brush Their Teeth?
As dementia and Alzheimer’s progresses, the senior may either forget to brush their teeth or not understand why they should do so. In the latter stages, they may swallow the toothpaste and not know how to brush their teeth (or even rinse out their mouth). They may also resist having someone help them with their oral care.
The Alzheimer’s Association suggests trying these ideas if you are wondering how do you get a dementia patient to brush their teeth:
- Provide short, simple instructions. Explain dental care by breaking directions into steps. “Brush your teeth” by itself may be too vague. Instead, walk the person through the process. Say: “Hold your toothbrush.” “Put paste on the brush.” Then, “Brush your teeth.”
- Use a “watch me” technique. Hold a toothbrush and show the person how to brush his or her teeth. Or, put your hand over the person’s hand, gently guiding the brush. If the person seems agitated or uncooperative, postpone brushing until later in the day.
- Try different types of toothbrushes. You may find that a soft bristled children’s toothbrush works better than a hard bristled adult’s brush. Or that a long handled or angled brush is easier to use than a standard toothbrush. Experiment until you find the best choice. Be aware that electric dental appliances may confuse a person with Alzheimer’s.
- Be aware of potential mouth pain. Investigate any signs of mouth discomfort during mealtime. Refusing to eat or strained facial expressions while eating may indicate mouth pain or dentures that don’t fit properly.
If you will be brushing the dementia patient’s teeth for them, tell them what you are doing before you attempt it.
- Have them sit in a chair by the sink so you can cradle and support their head.
- Stand on their dominant side (if they are right handed, stand on their right side). This helps them with fine motor “memory”.
- You hold the toothbrush and have them hold onto your hand that is brushing their teeth. Doing this makes their brain remember this movement and can make the person think they are actually the one doing the brushing.
- Put your hand on the person’s shoulder and apply downward pressure, which puts focus on that sensation and takes it away from the act of brushing (which they may resist).
- Talk about each step you are going to do before you do it so there aren’t any surprises for the person. Say something like, “Now I’m going to use this toothbrush,” then show it to them. “Next, I’m going to put it in your mouth and gently brush your teeth.” And so on…
- Don’t ever force their mouth open and don’t try to pry their lips open. If they won’t willingly open, take a break and try again later.
- Be patient. Have a consistent routine to keep oral care familiar.
- Know when quit – if the person gets agitated, stop for now. It won’t help to force them because doing so will only make it harder for you the next time you try.
- A children’s toothbrush is probably a better choice than an adult one. The head is smaller and can fit inside the senior’s mouth more easily, plus the bristles are softer. Other options if you just can’t get the senior to accept a toothbrush is to try rubbing their teeth with a Q-tip or something like the disposable toothbrushes or swabs I mentioned in the section above (How To Brush The Teeth Of A Bedridden Patient Who Is Alert).
Here’s a great video by Teepa Snow, a dementia care expert, so you can see these tips in action:
Remember that you should take the person in for regular dental checkups for as long as possible and try to keep up with their oral care for as long as you can. And you might consider taking the senior to the dentist more often than the standard twice per year if they are not brushing well (or at all). This way, any infections or cavities can be addressed before they have pain.
Of course, there will come a time when the person is not going to cooperate for the dentist or hygienist. At that point, you should discontinue their dental visits so they (or the dental personnel) don’t get injured. We had a lovely elderly lady in our dental practice who had dementia and had been doing really well with the dentist she’d been seeing for decades. The last time her son brought her in, though, she was very resistant to the hygienist.
The son requested that the dentist at least do an oral exam while his mom was in the chair. When the dentist approached her, the woman bit down on the dental mirror hard enough to break it. You can imagine how difficult it was to get all the broken pieces of mirror out of her mouth before she swallowed them!
Is A Dementia Patient Swallowing Toothpaste?
Although using a fluoride toothpaste is generally best in order to avoid cavities, if a senior with dementia or Alzheimer’s is swallowing it, it might be better to just use baking soda or plain water for brushing their teeth. Fluoride can cause stomach upset if a dementia patient is swallowing toothpaste and is a poison if too much is consumed.
For this reason, seniors in the later stages of Alzhemier’s and dementia should not use a fluoridated toothpaste or mouthwash and you should take care to lock your own fluoride-containing toothpaste up so they can’t get into it accidentally. If they have eaten it and you are concerned, know that MedlinePlus says,”The amount of fluoride in toothpaste is usually not swallowed in large enough amounts to cause harm.”
There are other toothpaste options for dementia patients, however, and they may be good choices for someone in the middle stages of the disease. In these cases, get a fluoride free toothpaste that contains xylitol. As I mentioned at the beginning of this article, Xylitol is a natural sweetener that helps to fight cavities.
You could also try a fluoride free children’s toothpaste. One with a mild mint flavor might be a better option (and more familiar) to the senior than one with the usual strawberry or bubblegum flavors that traditionally come in kid’s toothpastes.
Denture Care For Seniors
As a dental hygienist, I see this all the time – dentures, partials, and appliances like snore guards or bite guards can build up tartar, plaque, and stains just the same as natural teeth. This means that bacteria and fungi are hiding under the denture and in the nooks and crannies. You must remove them daily in order to avoid possible mouth problems!
If you wear dentures or any other oral appliance – you must brush your gums and the appliance. The American Dental Association (ADA) has resources about denture care for seniors on its website, MouthHealthy.org. They state that, “Like your teeth, your dentures should be brushed daily to remove food particles and plaque. Brushing also can help keep the teeth from staining.”
Here is the way the ADA recommends you care for dentures and other dental appliances (Note – this care routine applies to both full dentures or partials, and dentures and appliances made from acrylic or metal or both):
- Rinse your dentures before brushing to remove any loose food or debris.
- Use a soft bristle toothbrush and a non-abrasive cleanser to gently brush all the surfaces of the dentures so they don’t get scratched.
- Clean the denture while holding it over a soft towel or over a sink that is partially filled with water (and preferably lined with a washcloth). Dentures can break if you drop them on a hard surface like the sink, counter, or floor.
- When brushing, clean your mouth thoroughly—including your gums, cheeks, roof of your mouth and tongue to remove any plaque. This can help reduce the risk of oral irritation and bad breath.
- When you’re not wearing your dentures, put them in a safe place covered in water to keep them from warping.
- Occasionally, denture wearers may use adhesives. Adhesives come in many forms: creams, powders, pads/wafers, strips or liquids. If you use one of these products, read the instructions, and use them exactly as directed. Your dentist can recommend appropriate cleansers and adhesives; look for products with the ADA Seal of Acceptance. Products with the ADA Seal have been evaluated for safety and effectiveness.”
- Be wary of using dental adhesives for a long period of time if your dentures aren’t fitting well. The Food and Drug Administration (FDA) cautions that, “…an excess of zinc in the body can lead to health problems such as nerve damage, especially in the hands and feet. This damage appears slowly, over an extended period of time. Overuse of zinc-containing denture adhesives, especially when combined with dietary supplements that contain zinc and other sources of zinc, can contribute to an excess of zinc in your body.”
Additionally, the main ADA website says:
- Placing a denture in water (or a denture cleanser solution) when it is not being worn helps the denture retain its shape, remain pliable and keeps it from drying out.
- Dentures should never be placed in hot or boiling water, which could cause them to warp.
- Denture adhesives are not a remedy for ill-fitting dentures, which may need to be relined or replaced to prevent oral sores from developing.
One BIG additional step – ALWAYS remove dentures or partials at night. Never sleep with them in because the gum tissue underneath needs to breathe. My analogy to my senior patients is, “you wouldn’t go to bed with your shoes on, so why would you wear a denture to bed?” Those tissues have to breathe or you can get stomatitis. Web MD says, “Stomatitis, a general term for an inflamed and sore mouth, can disrupt a person’s ability to eat, talk, and sleep.”
I know, some people are concerned about how they look without their dentures. In that case, I recommend putting a bowl or denture container on the nightstand next to you. Make sure it has enough water in it to cover the denture and drop in a denture cleaner tablet just before getting into bed. Then, get into bed with the denture in your mouth, turn off the light, and then remove the denture and place it into the bowl. The next morning, get up and take the bowl into the bathroom, rinse the denture to remove the cleaning solution, brush the denture and your gums thoroughly, and put the denture back in your mouth for the day.
In my dental office, we recommend Polident Overnight Whitening Antibacterial Denture Cleanser because laboratory tests have shown that it kills 99.9 percent of oral bacteria. In addition, it helps to remove stains and brighten dentures. While the Polident 3-Minute Whitening Cleanser won’t kill as much bacteria, it can be helpful for reducing plaque and eliminating microbes if you are in a hurry.