Tackling a toothache can be difficult. For people with dementia, it can be incomprehensible. Their thinking is impaired and their ability to make decisions is diminishing. Eventually, they can’t even communicate their dental pain.

People with dementia rely on caregivers—family members and others—to notice that something’s amiss. How can caregivers best support a loved one’s oral health?

It’s a growing question, says Karin Arsenault, who is the Hilde H. Tillman, D49, Professor in Geriatric Dentistry and director of the geriatric dentistry program at Tufts University School of Dental Medicine. While much has been said about baby boomers’ aging, at 61 to 79 years old, they’re still younger than the country’s oldest adults. “We're really watching the 85-plus as the fastest growing demographic,” Arsenault says. In fact, their presence has increased notably since 2000. 

And although dementia—a progressive neurological condition caused by Alzheimer’s disease, vascular issues, Parkinson’s disease, and other medical problems—isn’t a normal part of aging, it is more likely to develop the older a person is. Consequently, “we're seeing an increase in the number of patients that suffer some level of dementia,” Arsenault says. “It’s a huge focus in geriatric dentistry right now.” 

To help loved ones and caregivers partner successfully with dentists as they care for people with dementia, Arsenault offers the following insights and tips. 

Know the Stages

Dementia unfolds over years and includes three stages: early, middle, and late. Helping a loved one with their oral care depends on adapting to each stage. 

In the early stage, symptoms include misplacing things and forgetting words. At this point, people can brush their own teeth and manage their own oral hygiene, Arsenault says. During this stage:

• Begin helping with toothbrushing and flossing. At first, “it might just mean going into the bathroom with them, standing there while the patient is brushing and flossing independently,” to build comfort with having someone present during a personal task.
• Take someone with dementia to the dentist for regular check-ups to ensure that the place, people, and routine remain familiar. 

In the middle stage, memory loss increases while confusion and behavioral changes begin. “This is where people start to require assistance,” Arsenault explains. During this time:

• Give instructions and mime what you want the person to do.
• Hang a “storyboard” depicting oral care tasks in the person’s bathroom.
• Use warm, rather than cold, water when helping a dementia patient with dental care.
• Consider a child-sized toothbrush with soft bristles. If that doesn’t work well, use an oral swab — and never put your fingers into someone’s mouth if they have dementia.
• Ditch the electric toothbrush. “The vibrations might be extremely disturbing to the patient,” Arsenault says.
• Help someone brush their teeth collaboratively by placing their hand over yours as you brush. “The patient is grasping your hand and they think they're in control while you are brushing their teeth,” she explains.

During late-stage dementia, people can’t communicate verbally, their mobility is affected, and they lack any independence. “Sometimes, they no longer tolerate their own dentures,” Arsenault says.

Even if someone with dementia can’t communicate how they feel, Arsenault recommends watching for key signals that their teeth or mouth need professional attention.

• Changes in eating habits. “They refuse certain foods,” Arsenault says. “They don't want certain foods: anything hard, anything cold, anything hot.” They might change to a completely soft diet or stop eating altogether.
• Visible facial or oral changes. “You might see some external swelling,” she explains. Inflammation, bleeding, or loose teeth might be visible inside the person’s mouth.
• Bad breath, or worsening bad breath. “Once there's an infection, bad breath gets a lot worse,” Arsenault says.
• Slapping or tugging at their face “because they want to get rid of the pain,” she explains. “They're going to be rubbing their cheeks and mouth.”
• Irritability and restlessness.

When caretakers notice these signs, they should check in with a dental professional. “There's really no harm or foul in picking up the phone and calling the patient’s dentist and explaining some of the changes you’ve observed,” Arseanault says. “The dentist will make a decision about having the individual come in.”

She recommends taking pictures of the person’s mouth with a cell phone and sharing them with the dentist. “There are even special devices that can be mounted to a cell phone, allowing you to open the person’s mouth and take a really good picture,” Arsenault adds. 

A Successful Dental Visit

To ensure that a trip to the dentist goes well, Arsenault recommends that caretakers:

• Vet a new dentist ahead of time, seeking a small, quiet practice. “Ask them what their experience is working with these individuals; some will be reluctant to treat them and will recommend someone else,” Arsenault says. “Others will be grateful to work with you and the patient.”
• Take a dementia patient to the dentist themselves, rather than someone unfamiliar taking to the patient.
• Streamline the process: fill out paperwork ahead of time and call the office upon arrival, such as from the parking lot, to bypass the waiting room.
• Be mindful of physical comfort: “Taking a warm blanket or a favorite sweater is very important, because dementia patients don't like the cold,” Arsenault says.
• Consider whether music or white noise might help the person and have it on hand.

Dementia at a Distance

Not every family lives near a loved one with dementia, and can’t assess them in person or take them to the dentist. Arsenault encourages families to communicate their dental care expectations with local caregivers and ask them to keep a log.

It’s also important to understand how familiar and comfortable hired caregivers are with home dental care. If they aren’t, “bring the dentist or a member of the dental team in to work with the caregiver and provide hands-on techniques,” she says.

In all stages of dementia, Arsenault suggests knowing what medications your loved one takes and telling the dentist.

Older adults are more likely to take medications that cause dry mouth, which “makes it more difficult to speak, to swallow, to retain dentures,” she says. Dry mouth also contributes to cavities, particularly for people who need help with oral hygiene. 

In cases where individuals with dementia are no longer able to make informed dental care decisions, there are legal frameworks, such as a durable power of attorney for health care or a health care proxy, to manage how those decisions are made.

Primary-care physicians and other members of the patient’s health-care team should also be consulted as necessary.

Arsenault encourages all caregivers to cultivate a calming presence while helping a dementia patient with their routine and emergency dental care. “Always be very calm,” she says. “Always be reassuring.”