Oral Care for Frail Older Adults and Denture Hygiene

Why it matters in frail older adults

• Pneumonia risk: mouth bacteria can be inhaled, especially with swallowing difficulty or lying flat; see swallowing problems (dysphagia) in older adults and pneumonia in older adults: prevention and recovery.
• Eating and nutrition: sore gums, loose or broken teeth, poorly fitting dentures and ulcers reduce appetite and cause weight loss; see dental health and eating and malnutrition in older adults.
• Comfort and speech: dry, painful, smelly mouths cause distress and withdrawal.
• General health: gum disease is linked with diabetes control, heart disease and infection risk; see diabetes after 60: a home care guide.
• Dementia: the person may forget how to brush, resist care or be unable to report pain; see caring for a parent with dementia at home.
• Dignity: fresh breath and a clean mouth matter to the person and those around them.

Common problems

Plaque, tartar and gum disease (red, swollen, bleeding gums, bad breath), tooth decay at exposed roots, dry mouth from many medicines, oral thrush (white patches, soreness), denture sores and non-healing ulcers are all common in frail older adults. Dry mouth raises the risk of decay and infection; do not stop any medicine without asking the doctor.

Basic equipment

• A soft toothbrush with a small head, or an electric toothbrush if tolerated. Replace every two to three months, or when the bristles splay.
• Fluoride toothpaste, a small, pea-sized amount, or less for people who cannot spit; high-fluoride toothpaste may be prescribed by the dentist for those at high risk.
• Foam swabs or a soft cloth for people who cannot tolerate a brush; they remove less plaque, so use a brush when possible.
• A cup, a towel and a bowl for spitting.
• A denture brush, denture cleanser tablets or mild liquid soap, and a container for soaking.
• Mouth moisturiser, saliva substitute or water-based lip balm for dry mouths. If oxygen is used, avoid petroleum jelly and oily products; see using an oxygen concentrator safely at home.

Cleaning natural teeth

Frequency: twice a day, in the morning and, most importantly, before bed. After meals if possible, or after vomiting or if food is retained.

Technique:

1. Wash hands, put on gloves, and explain what you will do. 2. Position the person upright, sitting in a chair or supported by pillows or a wedge in bed; see positioning a bedridden parent. If they must lie down, turn the head to the side so that liquid drains out and is not swallowed. 3. Wet the brush, apply a small smear or pea-sized amount of fluoride toothpaste. 4. Brush gently at a 45-degree angle to the gum line, using small circular or short back-and-forth strokes, covering all surfaces: outer, inner and biting surfaces of every tooth, for about two minutes in total. 5. Brush the gums and the tongue gently to remove coating, which reduces bad breath. 6. Let the person spit the foam into the bowl, or use a cloth to wipe it away. Do not rinse heavily if swallowing is unsafe, and do not pour water into the mouth of a person who cannot swallow safely or is drowsy. 7. Wipe the lips, and apply lip moisturiser. 8. Rinse the brush, and store it upright to dry, away from the toilet and other brushes.

Tips for resistance: approach calmly, use the same time and routine, play familiar music, explain simply, let the person hold the brush ("hand over hand"), brush a little at a time, and praise. If they clench their teeth, do not force; try later, or seek advice from the dentist or nurse. See dementia communication tips.

Caring for dentures

Dentures harbour plaque and fungus as readily as teeth, and a dirty denture is a common cause of sore mouths, infections and bad breath.

1. Remove the dentures after meals if possible, rinse them under running water to clear food, and rinse the mouth. 2. Clean at least once a day, ideally twice, over a basin half filled with water or lined with a towel, so that they do not break if dropped. 3. Brush all surfaces with a soft denture brush or a soft toothbrush and mild liquid soap or a non-abrasive denture cleaner. Do not use ordinary toothpaste, which is abrasive and scratches, or hot or boiling water, which can warp the denture, or bleach unless the dentist advises it. 4. Soak in a denture cleansing solution as directed, or plain cool water overnight, to keep dentures moist and prevent warping. Rinse thoroughly before wearing, particularly if a cleanser is used. 5. Take them out at night, to rest the gums and reduce the risk of thrush and pneumonia, unless the dentist has advised otherwise. 6. Clean the gums, tongue and palate with a soft brush or cloth each day, even if the person has no natural teeth. 7. Label the denture with the person's name, especially in hospital or care settings, since losing dentures is common. Store in a named container, never wrapped in tissue, which gets thrown away. 8. Check the fit. Dentures may loosen with weight loss or gum shrinkage. Poorly fitting dentures cause sores, trouble eating and falls in eating confidence. See a dentist for adjustment or relining. Denture adhesive may help in the short term but should not replace a good fit; consult the dentist. 9. Do not use dentures that are cracked or broken, and do not repair them with household glue. 10. Replace dentures as the dentist advises, often every five to ten years.

Mouth care for bedridden or very frail people

• Position safely, upright if possible, with the head turned and the chin slightly down, which reduces the risk of inhaling fluid.
• Use a small amount of toothpaste on a small brush, or a foam swab for people who cannot tolerate brushing, and remove foam with a damp swab or cloth. Use minimal water.
• Clean after every meal or at least morning and night.
• Look into the mouth with a torch for sores, white patches, food pocketed in the cheeks, loose teeth or bleeding.
• People with feeding tubes still need mouth care at least twice a day, since bacteria build up; see tube feeding and supplements basics.
• People on oxygen often have dry mouths; moisten the mouth, and use water-based lip balm.
• Prevent choking: if the person coughs or chokes during mouth care, stop, sit them up and seek advice from a speech therapist or doctor.

Dry mouth: what helps

• Sip water regularly, and offer small, frequent drinks; see hydration for older adults.
• Sugar-free lozenges or gum (if safe to chew) stimulate saliva.
• Saliva substitutes, mouth gels or sprays from the pharmacy, as advised.
• Review medicines with the doctor: do not stop any yourself.
• Brush with fluoride toothpaste, and ask the dentist about extra fluoride for high decay risk.

Oral thrush and sores

White or creamy patches that wipe off to leave a red surface, soreness or cracks at the corners of the mouth suggest thrush and need a doctor or dentist; clean dentures and leave them out at night, and rinse the mouth after inhaled steroids; see inhaler technique and spacers for older adults.

Warning signs: see a dentist or doctor

• A mouth ulcer, white or red patch or lump that does not heal within two to three weeks, particularly in people who use tobacco, pan, gutkha or alcohol. Oral cancer is serious but treatable when found early.
• Bleeding gums, loose teeth, pain or swelling.
• A swollen face or jaw, fever and a bad taste: a dental abscess; seek urgent care. If swelling spreads to the neck, makes swallowing or breathing difficult, call 112.
• Difficulty chewing, pain on eating or refusing food; see loss of appetite in older adults.
• Persistent bad breath despite cleaning.
• Poorly fitting or painful dentures.
• Unexplained weight loss.
• Difficulty swallowing or coughing with eating; see swallowing problems (dysphagia) in older adults.
• Fever, cough and breathlessness, which may signal chest infection.

Dentist visits

Ideally, see a dentist every six to twelve months, even with dentures; ask about home-visit or hospital dental services if travel is hard, and tell the dentist about conditions and medicines, including blood thinners and diabetes. Tobacco, pan and gutkha raise the risk of mouth cancer, so encourage stopping with medical help.

When to ask a professional

Ask a dentist to examine the mouth and dentures, treat decay, gum disease, ulcers and thrush, and recommend products. Ask a nurse or dental hygienist to show safe mouth care for a bedridden person. Ask the doctor about dry mouth medicines and swallowing. Seek urgent help for a swollen face with fever, trouble swallowing or breathing, bleeding that does not stop, or a mouth ulcer or lump that does not heal. Call 112 for breathing difficulty.