Delivery of Oral Home Care by Primary Caregivers

Common oral health problems in older individuals include: caries, periodontal disease, xerostomia, candidiasis, and mucosal lesions.^95,96 All of these conditions show an increased prevalence associated with age, likely due to age-related aggregation of risk factors, polypharmacy, and decline in dexterity leading to decreased efficiency in plaque removal.^96-100 These conditions are also more prevalent in individuals with cognitive impairment or dementia.^88,89 Older patients are also more likely to experience dysphagia, difficulty swallowing, which can make performing dental procedures in these patients more complex.^101,102

Individuals with dementia who reside in nursing homes often have poor oral hygiene associated with gingivitis and periodontitis^101,102 and oral hygiene practices are likely to be omitted or provided with chemical anti-plaque agents rather than toothbrushes. A failure to mechanically remove dental plaque on a regular basis is significantly less effective in preventing gingival inflammation and caries than mechanical plaque removal.^103-105 Because more than half of individuals with dementia rely on caregivers for many activities of daily living, including oral hygiene delivery, they are dependent on the knowledge and skills of others for their preventative oral health care.¹⁰⁶

One obstacle often encountered by primary caregivers is care resistant behavior (CRB) to oral hygiene delivery in patients with dementia. ¹⁰⁷ Care resistant behavior is defined as behaviors with which persons with dementia withstand or oppose the helping efforts of a caregiver and can be categorized as “uncooperative,” “disruptive,” or “agitation.”^108-113 Eighty percent of certified nursing assistants (CNAs) report CRBs in response to the delivery of oral hygiene,¹¹⁴ which have been shown to be reduced by increasing caregivers’ awareness of best practices for oral hygiene,^115-117 recognition of CRBs,^107,118 and strategies to reduce threat perception in patients with dementia.^{16,116,119,120} Some especially effective strategies for threat reduction during delivery of oral hygiene measures include: smiling, bridging (e.g., having the elderly patient hold a toothbrush while the caregiver is delivering oral hygiene), and the use of polite, one-step commands.^16,119, Inclusion of these simple steps in the oral hygiene routine of caregivers can increase cooperation for elderly patients with dementia significantly and improve oral hygiene quality and quantity.^16,119,