Knowledge

• Understand the importance of oral health in individuals living with dementia.
• Identify common oral health problems associated with dementia.
• Recognize changes in behavior that indicate increasing resistance or distress during oral care in individuals living with dementia.
• Determine situations where reporting to a nurse is necessary for further assessment.

Skills

• Demonstrate how to adapt brushing and flossing (if appropriate) techniques for individuals living with mid- to late-stage dementia.
• Use specific techniques:
  • Positive physical approach (hand-under-hand, demonstrating shoulder pressure) to minimize resistance to care
  • Supportive communication
  • Connection
  • Cueing and helping
  • Hand-under-hand assistance
• Recognize signs of oral pain and discomfort.
• Make informed decisions about when to escalate concerns to a nurse.

Attitudes

• Exhibit patience and empathy when providing oral care to an individual living with dementia.
• Value oral care as an essential component of overall well-being and comfort.
• Understand that oral care can be very stressful for individuals living with dementia.

Oral Care in Dementia Care--Why it Matters 

More than just clean teeth: Poor oral health in dementia significantly impacts:

• Comfort: Painful teeth, gum disease, and ill-fitting dentures cause distress.
• Nutrition: Difficulty chewing can lead to poor food intake and malnutrition.
• Overall health: Oral infections can increase the risk of systemic health problems like pneumonia.
• Dignity and social interaction: Stained teeth, bad breath, and discomfort cause self consciousness and withdrawal.

Challenges of Dementia

Cognitive Changes: Individuals with dementia may:

• Forget the purpose of oral care or how to perform it.
• Resist care due to misunderstanding or fear.
• Have difficulty expressing pain or discomfort.

Physical Changes: Some individuals develop:

• Limited dexterity, making brushing difficult.
• Increased sensitivity and gag reflex.

Direct Care Worker’s Role

• Prevention is key: Regular, gentle oral care helps prevent painful problems from developing.
• Detectives of discomfort: Direct care workers are often the first to notice subtle signs of oral problems and pain.
• Partnership with nurses: Reporting changes and working with nurses ensures proper treatment and pain management.

Key Takeaways

• Oral care is COMFORT care: Good oral hygiene significantly improves the quality of life for individuals living with dementia.
• Patience and creativity are essential: Adapt your approach to the individual's needs and abilities.
• Assist the individual in their own mouth care using various techniques:
  • Temperature (warm water)
  • Pressure on shoulder
  • Hand-under-hand
• You make the difference: Direct care workers are crucial in maintaining the oral health and wellbeing of those living with dementia.

1. Review objectives with learners.
2. Skill introduction:
   1. Hand-under-hand technique – demonstrate this with a learner.
      1. Gently placing your hand under the resident's hand and guiding the toothbrush together when a person living with dementia can no longer effectively complete the task.
      2. This is never about control; this is used to guide a person living with dementia and support them to maintain as much independence as possible.
   2. Gentle shoulder pressure – demonstrate.
      1. Applying light, reassuring pressure to the resident's shoulder can sometimes create a calming effect.
      2. It is effective while doing hand-under-hand and promotes safety for both the direct care worker and the person living with dementia.
      3. It should never be forceful or restraining.

This activity is a partnered activity. There are two scenarios. Partners will take turns being the direct care worker or an individual living with dementia. After each scenario, the participants will answer guided questions and participate in a facilitator-guided debrief.

1. Select who will be partner 1, and who will be partner 2.
2. You will watch a brief video and then do the scenario.

After completing the scenarios, the facilitator will either lead a small group reflection (Option A), or a large group debrief (Option B).

Overview

Resident Profile: Roberta Bennett, early mid-stage dementia, generally cooperative but sometimes becomes confused and forgets the purpose of daily tasks.

Watch this video from start to 3:22: Link: https://www.youtube.com/watch?v=6uT5iz0tsMQ

Task: Provide routine morning oral care, including brushing and flossing (if appropriate).

Challenges:

• Roberta Bennett might not understand instructions and needs gentle reminders.
• She may close her mouth or turn her head away from the toothbrush.

Focus:

• Clear, simple communication and demonstration.
• Patience and offering short breaks, if needed.
• Use objective evidence and supportive language rather than point out mistakes.
• Use the phrase “Try this.”
• Use “I’m Sorrys” if the person becomes agitated.

Scenario 1 Roleplay Guide: Direct Care Worker

Resident Profile: Mrs. Roberta Bennett

• Mid- to late-stage dementia. May have very limited verbal communication and difficulty understanding complex instructions.
• History of becoming agitated or upset during personal care, especially tasks that involve the head and mouth area.

Tasks:

• Attempt to assist Roberta Bennett with routine oral care (brushing and flossing if you have been trained in this).
  • If Mrs. Bennett seems confused by instructions, try demonstrating the action yourself (brushing your own teeth).
  • Say, “The dentist wants us to try something.” Demonstrate on yourself, not on the individual living with dementia.
    • You will need a toothbrush for yourself to demonstrate (keep it in your pocket).
• Prioritize Mrs. Bennett’s comfort and safety. Perfect cleaning is less important than minimizing distress.
• Try different communication approaches:
  • Break tasks into very small steps
  • Use “Try this” with gestures – change your wording or actions if something is not working (say and demonstrate, pointing)
  • Try one of the following approaches:
    • brushing on right side
    • brushing on left side
    • rinsing your mouth
    • drying your face
• If agitation is strong, use an "I'm Sorrys" apology to de-escalate if appropriate
  • “I’m sorry this is bothering you.”
  • “I’m sorry this is hard.”
  • “I’m sorry, let's take a break."
  • “I’m sorry, how about we brush your hair first.”
  • “I’m sorry, why don’t you show me what you would like to do first.”
• It may be useful to take a break for a few minutes to allow agitation to subside. Remember, even getting oral care partially completed is better than no oral care.

Things to Notice:

• Roberta Bennett's nonverbal cues (facial expressions, body language, sounds).
• What triggers stronger resistance? Specific actions or words?
• Are there moments where she seems calmer or more receptive?

Roberta Bennett's (RB) Care Plan

Special Instructions:  Very limited verbal communication, mid to late-stage dementia, history of agitation (during personal care, especially tasks involving the head and mouth area)

Scenario 1 Guide: Person Living with Dementia

Your Profile: Roberta Bennett

• You have trouble understanding what people are saying and doing, especially when things happen quickly.
• You do not like people touching your face or being inside your mouth – it feels confusing and even scary sometimes.
• You do not always understand why people want you to do certain tasks.

During the Care:

• Show that you are confused: frown, look away, seem unsure what is happening.
• Instead of just resistance, include moments of hesitation or looking unsure of what to do.
• If the direct care worker shows you the action, try to copy them to the best of your ability.
• If the direct care worker does something that feels uncomfortable, resist:
  • Pull away, turn your head, close your mouth tightly.
  • Make sounds of discomfort.
• Increase agitation if the direct care worker does not stop or change their approach.

Debrief Focus: If you can, tell the group what made you feel scared or upset. Explain what the direct care worker could have done differently that might have made it easier.

Scenario 1: OPTION A Reflection with Your Partner

Understanding Cues:

• Direct Care Worker: Were there any signs from Mrs. Bennett that helped you understand if she was confused or unsure?
• Roberta Bennett: Can you share a time when you felt like the direct care worker understood how you were feeling?

Turning Point: Was there a specific moment where things seemed to shift, and the care became easier? What do you BOTH think changed in that moment?

Communication Success:

• Direct Care Worker: What is one communication strategy you tried that felt successful?
• Roberta Bennett: Did you notice the direct care worker change how they spoke or acted? Did that help?

Individual Follow-Ups:

• Direct Care Worker: If you could try one thing differently next time, what would it be?
• Roberta Bennett: What is one thing you wish the direct care worker had done or said to make the care easier?

Overview

Resident Profile: John Jones, late-stage dementia, prone to agitation and misunderstanding, especially during personal care routines. History of becoming agitated and resistant during oral care, especially tasks involving the mouth. May exhibit physical resistance such as pulling away and pushing hands.

Watch this video from start to 3:08:

Link: https://www.youtube.com/watch?v=9NbqBS4evIs

 

 

Task:

• Attempt to provide basic oral care (focusing on brushing) for Mr. Jones while prioritizing his comfort and safety.
• Use communication strategies including short, clear instructions and a calming voice.
• Be prepared to offer choices if possible (e.g., "Which toothbrush would you like?").
• If Mr. Jones remains resistant, try the following:
  • Hand-under-hand: Gently place your hand under his and attempt to guide the toothbrush together.
  • Gentle pressure: While using hand-under-hand, try applying light pressure to his shoulder to offer a sense of grounding.
• If agitation increases, utilize de-escalation techniques, including the "I'm Sorrys."
• Be observant for signs of discomfort or pain and be prepared to pause care if necessary.

Challenges:

• De-escalating agitation, calming Mr. Jones.
• Deciding whether to postpone oral care and try again later.

Focus:

• Use soothing techniques (soft voice, distraction with a favorite object).
• Recognize when to stop and try a different approach, or at a different time.
• Use hand-under-hand technique during oral hygiene (with Mr. Jones’s dominant hand).
  • Gently place your hand under his and attempt to guide the toothbrush together.
• Provide dominant side shoulder gentle pressure to distract John Jones from agitation in oral care.

Scenario 2 Guide: Direct Care Worker

Resident Profile: Mr. John Jones

• In the late stages of dementia. His communication is limited, but he may respond to nonverbal cues and simple instructions.
• Often becomes resistant during oral care.

Your Approach:

• Start with basics: Begin by attempting regular oral care using clear instructions, a calming voice, and offering choices if possible (e.g., “Blue brush or red brush?”).
• Observe and adapt: Pay close attention to Mr. Jones’s reactions. If he resists strongly, try the following:

  • Hand-under-hand: Gently place your hand under his and attempt to guide the toothbrush together.

  • Stabilizing pressure: While using hand-under-hand, provide gentle, reassuring pressure to his shoulder with your other hand. This helps increase control and safety.

• De-escalate if needed: If agitation increases, prioritize calming Mr. Jones. Utilize de-escalation techniques, including the “I'm Sorrys”.

• Pain awareness: Be observant for signs of discomfort (grimacing, pulling away even more) and adjust your care accordingly.

Remember:

• Comfort and safety first: Prioritize Mr. Jones’s wellbeing over completing the task perfectly.
• Communication is key: Even with limited verbal response, your tone of voice and touch matter.
• Be prepared to report to the nurse if the task cannot be completed, and if you observed any signs of discomfort.

John Jones’s (JJ) Care Plan

Special Instructions:  Latestage dementia, agitation and misunderstanding during personal care, resistant to oral care, may pull away or push hands.

Scenario 2 Guide: Person Living with Dementia

Your Profile: John Jones

Demonstrate Resistance:

• Pull away, shake your head, or turn away when the direct care worker approaches with the toothbrush.
• Increase agitation if the direct care worker persists without changing their approach.

Potential Responses:

• If the direct care worker uses hand-under-hand, slightly decrease your resistance, allowing some guided movement.
• If the direct care worker applies gentle shoulder pressure, show subtle signs of relaxation (lessening body tension) if it feels calming.

Scenario 2: OPTION A Reflection with Your Partner

1. Shared Observations: Begin by jotting down your top 3 observations about the other person’s behavior during the scenario.
2. Comparing Perspectives: Partners share their observations with each other. Discuss:
   1. Were there any surprises? Did you notice the same things?
   2. Were there specific actions or words that felt helpful or unhelpful from the other person’s perspective?
3. “Try Again” Moment:
   1. Choose ONE moment from the scenario where communication or care went poorly.
   2. Brainstorm TOGETHER: What could have been done differently? Focus on actions both the direct care worker and the “resident” could take.
4. Empathy Building:
   1. Direct care worker: Describe how it felt trying to provide care to someone who was resisting and potentially in discomfort.
   2. Mr. Jones: Try to articulate the most frustrating or confusing part of the experience.

Facilitator Tips:

• Link to scenarios: Use learner examples to tie back to early- vs. late-stage differences.
• Call on variety: Aim for a mix of direct care worker and “resident” voices to be heard.
• Closing point: Emphasize how increased understanding makes them better equipped to provide compassionate AND effective care.

Supplies

• Handouts with learning objectives and activity overview (enough for the number of participants)
• Scenario guides for each participant group
• Toothbrush for each participant
• Optional: washcloths and cups (for simulation purposes), sink setup

Equipment

• Individual devices (to watch prompt video) OR a screen with a projector to play videos for everyone together.

Setup

• Arrange chairs for partnered activity (facing each other or next to each other in a shared space).
• Provide supplies (handouts, toothbrush at each station).

Notes

• This activity is designed to take 30 minutes, with 10 minutes allocated for each scenario and 10 minutes for debriefing.
• The target audience is direct care workers and learners working in long-term care or dementia care settings.
• The facilitator can adjust the difficulty of the scenarios based on the experience level of the participants.