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Mouth care: Reducing resistant behaviors

July 15, 2011
by Rita A. Jablonski, PhD, CRNP
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More elders are entering long-term care with their natural teeth, and those who develop dementia will require help with mouth care. Resistance to mouth care refers to behavior ranging from a simple turning away of the head and refusal to open the mouth to more aggressive pushing and kicking. My research team approaches care resistance within the context of threat perception; that is, the elder with dementia sees the caregiver as a threat and fights, flees or freezes. The team developed and tested several strategies to avoid resistance during mouth care called Managing Oral Hygiene Using Threat Reduction (MOUTh), which has been supported with a $1.4 million research grant from the National Institutes of Health. Using these strategies, we were able to provide comprehensive mouth care to persons with dementia who consistently resisted oral hygiene.




The first strategy is to simplify the environment as much as possible. The least amount of noise and activity is best. Turn off televisions and radios. Use touch judiciously; it is best to gently touch the parts of the body farthest away from the point of care, such as the hands. If touch calms the elder, one may touch the forearm or shoulder as an act of reassurance. The nurse should approach the elder with a friendly, smiling countenance and speak in a low-pitched voice using short sentences and simple, one-step requests.

One common antecedent for mouth-care–resistive behaviors is the use of elderspeak, a term used to describe “baby talk” speech patterns inappropriately employed with older adults. This includes high pitches, short sentences, singsong cadences, patronizing tones and use of collective pronouns and infantilizing terms. Conducting care in absolute silence, on the other hand, may also perpetuate the elder's perception that they are being mistreated.

Rita jablonski (right) uses an actor to demonstrate the mouth approach.
Gene Maylock, © 2008 Penn State School of Nursing/Center for Excellence in Geriatric Nursing
Rita Jablonski (right) uses an actor to demonstrate the MOUTh approach.

When rinsing the mouth, use tepid water. Many older adults have gingival recession, which exposes more of the sensitive root. Judicious use of topical analgesics may prevent and reduce care-resistant behavior—pain is a common precipitant. Many persons with dementia have difficulty processing verbal explanations and requests, and will better respond to gestures and pantomime. Combine gestures and pantomime with all verbal interactions. For example, to get the elder to spit, the nurse may have to pantomime spitting in the sink. Flossing is another challenge. We found that proximal brushes worked well and were accepted by elders.

Distraction can be useful in preventing and limiting care-resistive behaviors. One type of distraction—bridging—involves having the elder hold a toothbrush while the nurse brushes the teeth. Other modes of distraction include singing, playing music or holding a stuffed animal or baby doll. The use of stuffed animals or dolls is not an attempt to infantilize the elder; some older adults are comforted by these objects. For example, one elder cherished her stuffed dogs and cats and was most cooperative during mouth care if we gave her one to hold. Another lady would only participate if the caregiver sang.

Providing mouth care to persons with dementia can be challenging. These strategies should help nursing staff provide comprehensive oral hygiene and, in turn, promote the overall health of their patients.

Rita A. Jablonski, PhD, CRNP, is an assistant professor at The Pennsylvania State University School of Nursing. She is the principal investigator of an active four-year NIH-funded study designed to examine best methods for the provision of mouth care to nursing home residents with dementia.
Long-Term Living 2011 July;60(7):54

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Comments

Thank you for writing on oral hygeine care for long term care residents. As a hygeinist and caregiver for 5 years, I've witnessed and learned the challenges of providing oral hygeine care for seniors. I've provided in-service training for CNA's on oral hygiene care for seniors with tips and devices for care. There is a huge need for oral hygeine care in this growing patient poplulation. I plan to share this well written article with the nursing staff. Jackie Dorst, RDH