Brushing

The following brushing guidelines should be reinforced to nursing staff. Adhering to universal brushing standards is essential for maintaining oral health in all patients. These standards include:

• Wash hands and wear new gloves before performing oral care.

• Position the patient upright or have them stand at a sink if applicable.

• Brush at least twice daily for two minutes each time.⁹

• Use a soft-bristle toothbrush; electric toothbrushes are preferred for their effectiveness.¹⁰

• Brush all natural teeth and dentures, covering all tooth surfaces including the biting surfaces.

• Clean the patient’s tongue to remove bacteria.

• Rinse the mouth with water after brushing.

• Replace the toothbrush or toothbrush head every three months, after illness, or when bristles become frayed.¹⁰

When planning oral care, consider whether the resident can brush independently, requires assistance, or is unable to provide care for themselves.

Monitoring & Assisting

Even if a resident can brush their own teeth, caregivers should monitor to ensure effective brushing. For residents with memory issues, reminders or visual cues, such as placing the toothbrush on the sink, may be helpful.¹⁰ Caregivers may need to assist by applying toothpaste and initiating the brushing process.

For residents who are capable of self-care but struggle with manual dexterity, caregivers can use a hand-over-hand technique to guide the brush. Positioning behind or beside the patient, the caregiver places their hand over the resident’s hand to assist with brushing while allowing the patient to participate actively.⁷ Electric toothbrushes are advantageous due to their effectiveness over manual toothbrushes, as are wide, ergonomic handles, and smaller brush heads that fit into limited mouth openings.¹¹

For residents with limited grip strength, such as those who have had a stroke, modifications can enhance their ability to brush independently. Adding foam tubing, tennis balls, or ergonomic grips can make the toothbrush handle larger and easier to grasp. If gripping is no longer possible, a utensil holder or rubber band can be used to secure the toothbrush to the resident’s hand.¹¹

Figure 2 - Toothbrush Modifications¹¹

Figure 2 - Toothbrush Modifications¹¹

Providing Care

When providing oral care for residents who are unable to perform it themselves, caregivers must exercise patience, clear communication, and adaptability. Always explain the procedure to the resident before starting, even if they may not be able to respond. Clear communication helps set expectations and can ease any discomfort or anxiety, ensuring the resident remains calm and cooperative.

Some patients have difficulty opening or staying open. In such cases, caregivers can use a foam bite guard, mouth rest, or the two-toothbrush technique to help maintain an open mouth.¹¹ The two-toothbrush technique involves using the handle of a second toothbrush as a bite block while performing oral care. This method helps prevent jaw fatigue and accidental biting, making the procedure more comfortable for the resident.

Removing toothpaste from residents’ mouths can be difficult. If possible, guide them to expectorate into a sink, cup, or towel. If they cannot do this or if rinsing is not feasible, use a damp cloth or gauze to gently wipe their mouth clean.¹¹ This method helps maintain effective oral care while accommodating the resident’s abilities.

Figure 3 - Two-Toothbrush Technique¹¹

Figure 3 - Two-Toothbrush Technique¹¹

Mouth Care for Unconscious or Immobile Residents

For residents who are unconscious or immobile, mouth care must still be performed twice daily. In these cases, mouth swabs or oral sponges can be used in place of a toothbrush and toothpaste to remove plaque. Caregivers should position the resident’s head to the side during the procedure to prevent swallowing, aspiration, or choking.

Tongue Brushing

A significant amount of plaque accumulates on the tongue. It is essential for caregivers to include tongue brushing in every mouth care routine and to monitor the tongue for changes in color or coating, documenting any variations observed. Neglecting the tongue can leave harmful bacteria in the mouth, increasing the risk of oral and systemic diseases, particularly if aspiration occurs.

Reporting

Nurse aides and caregivers play a crucial role in detecting oral health issues. As they conduct daily mouth care, they should be trained to identify and document any abnormalities. Healthy oral tissue should be pink, firm, and moist, without bleeding. Any white or red lesions, as well as cracks, chips, or dark areas on the teeth, should be documented and reported for follow-up care. Additionally, caregivers should ask daily screening questions such as, “Do you have any pain in your mouth?” or “Is anything in your mouth bothering you?” to uncover potential issues that may require further attention.