It is necessary that all long term care residents, especially those with dementia, have a daily oral hygiene care plan. This preventive care, when performed daily, saves the tremendous cost of treating oral disease and providing emergency dental care. As dementia advances, and some residents lose the capacity to communicate when they feel pain, daily oral hygiene care becomes even more imperative to prevent pain and infection.

Collaboration Key

By definition, all of the long term care facility’s caregivers—medical director, medical attendings, nursing staff, and certified nurse assistants (CNAs)—are committed to providing the best possible care for the resident as detailed in their interdisciplinary care plans.

Most of the daily oral care is provided by CNAs, who play an important part in a resident’s oral hygiene routine. It is the nursing staff’s responsibility to ensure the care occurs as directed by the dentist and/or dental hygienist in the plan.

This collaborative effort among nurses, CNAs, resident, and family is illustrated by an award-winning video. The 1992 video, published by the South Texas Geriatric Education Center and funded by a U.S. Department of Health and Human Services grant, is still pertinent today and teaches daily oral care for long term care residents who are conscious and unconscious. The video, “Oral Health Care—A Guide for Nurse Aides and Other Caregivers,” portrays CNAs on their rounds as they execute proper dental care, including brushing and denture maintenance, for residents who are aging, immobile, or bedbound.

Some key points include the importance of observation and CNAs reporting to the charge nurse if anything in the mouth is abnormal, such as broken teeth or dentures, and any sores on gingivae/gums or other soft tissue. The video also illustrates the concept of an advanced CNA whose job it is to perform or assist in this care for residents who cannot do it all by themselves.

A career ladder can be developed to train CNAs to take the role of director of the nursing facility’s Oral Hygiene Care Program. This designation gives the CNA an important responsibility, as well as recognition for the leadership role. The advanced CNA is responsible for assuring that daily oral hygiene care is provided at the necessary care level (coaching, partial assistance, or full provision of care) as detailed in the plan, and for training all new CNAs as required by their knowledge and experience. It is expected that each CNA providing daily oral hygiene care will also screen the resident’s mouth for problems.

Back to Basics

When it comes to day-to-day cleaning, it helps to review the basics. The first rule to follow before brushing or examining a resident’s mouth is to not forget to wear gloves. Wearing gloves prevents acquiring an infection in the CNA’s or nurse’s finger, such as herpetic whitlow, also known as whitlow finger.

Make sure to clean any removeable partial or full dentures over a wet towel in the sink to prevent breaking them. Clean each prosthesis morning and night. Place clean dentures overnight in liquid in a cup, replacing them in the mouth in the morning. Cleanse the soft tissue under full or partial dentures using very damp plain swabs or gauze, being careful not to tear the soft tissue.

Do NOT use lemon glycerin swabs on the natural teeth instead of a toothbrush because the swabs will make a dry mouth worse and will not remove the plaque on the teeth.

Be sure to hold the toothbrush bristles at a 45 degree angle to the gumline and clean tooth to tooth, not missing any surface, and avoiding soft and hard tissue damage by not scrubbing the gums or teeth.

Toothpaste Choice Makes a Difference

Residents with dementia might better appreciate using children’s toothpaste since it foams less. Brush the resident’s teeth twice a day with a fluoride toothpaste, preferably one with more fluoride rather than less.

Ask the dentist to prescribe a strong fluoride toothpaste that also foams less and a special mouth rinse if the dentist thinks it is warranted for the individual resident with dementia. Make the prescribed toothpaste and rinse part of the resident’s daily oral care plan.

Floss the resident’s teeth once a day using a floss holder, squeezing the prongs when threading the holder so the floss will be tight after releasing the “squeeze” when threading the holder is complete.

Each resident with teeth should have a new toothbrush every three months.

Interacting with Residents in a Gentle Manner

Tell the resident with dementia everything that will take place, speaking slowly and using simple words and short sentences. Do not make any sudden moves or accidentally flash a light in the eyes of a resident with dementia. This can help the resident avoid having a whole-body reaction in which his or her arms flail.

When the resident needs professional dental treatment and if the resident is incapable of cooperating with the dentist or hygienist, sedation prescribed by the attending physician or dentist might be necessary.

Each partial and full denture should have a label identifying the owner. 

Both partial and full dentures should be labeled using a nail file to roughen a spot on the pink outside of the denture. The roughened spot should be large enough to print the owner’s last name on it with a SharpieTM or similar permanent marker. Then the name should be covered with a strong, clear nail polish such as Sally Hansen Hard as NailsTM or similar product to protect it.

This identification will last six months to a year. If a prosthesis gets lost or fits poorly, the dentist should make a new one, and will have the lab insert a proper, permanent identification in the full or partial denture.

Benefits for Residents are Critical

In order to make a difference in improving the oral care of each resident, be patient with oneself and the resident with dementia. When proper daily oral hygiene care is provided, nursing staff can help prevent aspiration pneumonia, as well as septicemia with oral bacteria, which could have contributed to pain, myocardial infarction, stroke, or other infection. In addition, systemic diseases such as diabetes are more easily controlled and managed if the resident has no oral infection.

If a resident with dementia is not in oral pain, then there could be fewer behavioral management issues when the resident can no longer easily communicate his/her distress. There is no doubt that proper daily oral hygiene care can prevent disease and result in a higher quality of life for residents.

Michèle Saunders, DMD, MS, MPH, is adjunct professor and director of the South Texas Geriatric Education Collaborative in the Departments of Psychiatry and Periodontics at the University of Texas Health Science Center at San Antonio. She can be reached at: or 210-859-6299.