Oral Care in Long Term Care Communities

June 7, 2025

Submitted by Dr. Joy Poskozim DDS FSCD CDP

Founder of Joyful Dental Care – House Calls, Advocate, & Presenter

Geriatric House Call Dentist for over 15 years, Dr. Joy Poskozim speaks to Long-term Care Facility Administrators, Nursing Staff, Caregivers, and loved ones on the importance of oral health care as we age. Her goal is to share as much dental information as possible, thereby making it easier to communicate to traveling dentists on what oral health problems residents may have.

Having provided oral care for the geriatric community for over fifteen years, Joy understands medical conditions – and the subsequent issues revolving around them – supersede oral care.

Tell – Show – Do is my favorite technique

I love this photo. It speaks volumes to me.

At first glance I see an adorable couple brushing their teeth together.

First Impressions Can Be Deceiving

As I continue to look, however, I see the gentleman is holding his toothbrush in a peculiar way. Arthritis? Diabetic neuropathy? Tendonitis? Carpal Tunnel Syndrome?

Did OT or PT help him get back to this point from a stroke or fall?

He is not applying a lot of force onto his teeth this way, so how well is he really brushing?

I also see how he is hunched over. One cannot see his left hand, but I am going to assume he is holding himself up with it.

I then notice that she is watching him brush his teeth. Is she monitoring him to make sure he is brushing correctly?

There are many ways we can help provide care for our loved ones, as well as monitor their activities of daily living – especially if they live with us. But how well are they being observed in long-term care facilities. And, is oral care even included in ADL’s?

This is literally one of my slides that I present to my dental colleagues on the lecture circuit. When did “toileting” become a thing? AND where does brushing teeth come into play?

This is the definition for rehab facilities. When does the OT/PT help their client take the cap off the tube of toothpaste, relearn how to put the toothpaste on the toothbrush, and bring the toothbrush to the client’s mouth?

I have found that unless the Director of Nursing is adamant about daily oral care for the residents in AL, Memory Care, Skilled, Hospice, brushing teeth after meals doesn’t get done because it is not a priority. So is not having good routine oral care for these residents NOT a sign of neglect?

My greatest concern is making sure the caregivers who are directly providing daily care for their residents have a sense of the importance of oral care.

Bad Breath Is One Of The Biggest Complaints

Their biggest complaint, I have learned, is bad breath. And, yes, halitosis can definitely be difficult to deal with.

Bad breath usually comes from the tongue, followed by in between the teeth. So brushing teeth is the #1 way to help reduce mouth malodor. #2 is staying hydrated. Neither of which my memory care patients like very much.

One of the things I learned from becoming a Certified Dementia Practitioner is not only do I want to make direct eye contact with them, I also want to be at their level.

No matter what, we are still equals, and I never want anyone to feel that I am talking down to them. Being 5’11” myself, I am supersensitive on making sure I converse with my resident-patients sitting, or even kneeling next to their wheelchair. Anything I can do to make them feel more comfortable. Another reason why I like to provide oral care in the comfort of their own rooms. I am their guest in their home. This is critical for me.

I mention this because in order for me to be able to convince one of my Memory Care residents that we are going to brush their teeth, I want to make sure that not only I can do this, but the caregivers watching me can replicate what I do.

Tell – Show – Do is my favorite technique

TELL: “Henry, we are going to brush your teeth now.”
SHOW: Have Henry point to his toothbrush in his bathroom, and, even better yet, have him give the toothbrush to you.
1. Show Henry the toothbrush, and, if possible, have Henry watch the toothpaste being put on, or have him do it.
DO: “Henry, I am going to brush your upper right teeth now by lifting up your upper lip.”
1. “Henry, I am going to brush your lower right teeth now by dropping your lower lip.”

If Henry can watch this being done in his bathroom mirror, this is ideal.

If brushing teeth has to be done knee to knee or alongside to make it easier for the caregiver, resident, or both, fantastic.

If brushing has now become a two-person job, where one is brushing and the other is helping control the situation so the brusher won’t get hit or kicked, so be it.

This may not always be possible as there are many residents that need to be taken care of. Including a loved one if they come on a regular basis, or a volunteer/intern is also incredibly helpful.

Using Mouthwash Can Help On Several Levels

After brushing, using a mouthwash such as Biotene (that can be swallowed if no longer responding to commands) or an alcohol-free mouthwash to prevent dryness or excessive tingling, OR using a dry mouth mouthwash twice daily after brushing can also help prevent bad breath. But, like anything else, these steps need to be done consistently on a daily basis. Just as important as any other medication, OT or PT activity they are doing.

Nope! These Are Not Candies

Nope! These are not candies, but they sure do taste good. With at least three different flavors, Jelly Drops are an innovative sugar-free treat, made of 95% water with added electrolytes & vitamins, designed to increase fluid intake.

These have only recently made it to the US, but are easy to incorporate for better hydration/less bad breath.

Unfortunately, coffee and tea also cause bad breath because they are dehydrators.

Yes! Coffee and tea – all forms/types/brands – do not help to hydrate the body, but instead use saliva to be processed and then swallowed. Ever heard of coffee breath?

Caregivers Are Concerned About Losing The Ability To Swallow, or Dysphagia

These are the most common signs/symptoms:

Weight Loss
Refusal To Eat
Refusal To Open Their Mouth
Leaves Food On Plate
Spits Out Food
Coughs while Eating
Does Not Swallow
Touches Throat Or Chest While Swallowing
Drooling
A Wet Or Gurgly Voice
Chews Without Swallowing
Recurrent Urinary Tract Infections Due To Dehydration

This is when hoarding food, otherwise known as “squirreling,” can take effect with our memory care patients. They will chew but not swallow, instead pocketing the food between the teeth and cheeks. This also circles back to bad breath: food decaying in the mouth.

Swabbing the mouth after meals becomes part of this person’s regular routine, and moving from a Regular Diet -> Mechanical Soft -> Pureed needs to be discussed with the PCP and dietician/nutritionist on staff.

Adding thickeners to one’s water/drinks also helps prevent dehydration, but most, if not all, have a significant amount of sugar. I immediately put my memory care patients on prescription Fluoride toothpaste to be used twice daily after meals to help prevent cavities because this stuff stays in the mouth on the teeth.

Bottom Line: Everyone Is Different, And Everyone’s Dementia Experience Is Different

Thinking outside the box to help our residents maintain their smiles by brushing their teeth is crucial in preventing not only bad breath, but also helping to slow down the effects of swallowing problems.

Comments/questions? Never hesitate to contact me!