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Oral Hygiene & Care-resistant Behaviors: Making a Difference


Oral Hygiene & Care-resistant Behaviors: Making a Difference

Rita Jablonski, MD
Hartford Geriatric Nursing Initiative (HGNI)
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Date Reviewed/Updated for Clinical Accuracy: 

This video addresses care-resistant behavior exhibited by persons with dementia within the context of oral hygiene. Care-resistant behavior includes any actions on the part of the person with dementia to evade or avoid activities of daily living. Care-resistant behavior is theorized to be a reaction to a perceived threat; that is, the person with dementia interprets the caregiving activity as an assault or sees the caregiver as a person intent to doing harm. Oral hygiene activities, such as brushing the teeth or removing dentures, involve close proximity between the elder and the caregiver. This closeness heightens threat perception on the part of the elder with dementia. Several strategies to prevent and reduce care-resistant behavior are described and depicted in the video. Some of the strategies include promoting as much independence as possible, using nonverbal communication, and avoiding elderspeak.

Educational objectives: 

After watching this video, participants will be able to:

1. Describe how caregiving activities can be misinterpreted as threat by persons with dementia;

2. Identify care-resistant behavior in the context of oral hygiene activities;

3. Demonstrate at least one technique to prevent or reduce care-resistant behavior during oral hygiene activities.


Additional information/Special implementation requirements or guidelines: 

Content in this video was based on the following sources:

Oral-Systemic Link

      Azarpazhooh A, Leake JL. Systematic review of the association between respiratory diseases and oral health. J. Periodontol. 2006;77(9):1465-1482. doi:10.1902/jop.2006.060010.

      Bakhshandeh S, Murtomaa H, Mofid R, Vehkalahti MM, Suomalainen K. Periodontal treatment needs of diabetic adults. J. Clin. Periodontol. 2007;34(1):53-57. doi:10.1111/j.1600-051X.2006.01028.x.

     Furukawa T, Wakai K, Yamanouchi K, et al. Associations of Periodontal damage and tooth loss with atherogenic factors among patients with type 2 diabetes mellitus. Intern. Med. 2007:1359-1364. doi:10.2169/internalmedicine.

    Desvarieux M, Demmer RT, Rundek T, et al. Periodontal microbiota and carotid intima-media thickness: the Oral Infections and Vascular Disease Epidemiology Study (INVEST). Circulation. 2005;111(5):576-582. PMCID:PMC2812915.

     Desvarieux M, Demmer RT, Rundek T, et al. Relationship Between Periodontal Disease, Tooth Loss, and Carotid Artery Plaque: The Oral Infections and Vascular Disease Epidemiology Study. Stroke. 2003(9):2120-2125. PMCID:PMC2677013. doi:10.1161/01.STR.0000085086.50957.22.

      Promsudthi A, Pimapansri S, Deerochanawong C, W. K. The effect of periodontal therapy on uncontolled type2 diabetes mellitus in older subjects. Oral Dis. 2005;11:293-298. doi:10.1111/j.1601-0825.2005.01119.x.

      Quagliarello V, Ginter S, Han L, Van Ness P, Allore H, Tinetti M. Modifiable risk factors for nursing home-acquired pneumonia. Clin. Infect. Dis. 2005;40(1):1-6. doi:10.1086/426023.

     Terpenning M. Geriatric oral health and pneumonia risk. Clin. Infect. Dis. 2005;40(12):1807-1810. doi:10.1086/430603.


Care-Resistant Behavior as Response to a Perceived Threat

      Corcoran KA, Desmond TJ, Frey KA, Maren S. Hippocampal inactivation disrupts the acquisition and contextual encoding of fear extinction. J. Neurosci. 2005;25(39):8978-8987. doi:10.1523/JNEUROSCI.2246-05.2005.

      Henry JD, Thompson C, Ruffman T, et al. Threat perception in mild cognitive impairment and early dementia. J. Gerontol. B Psychol. Sci. Soc. Sci. 2009;64B(5):603-607. doi:10.1093/geronb/gbp064.

      LaBar KS, Torpey DC, Cook CA, et al. Emotional enhancement of perceptual priming is preserved in aging and early-stage Alzheimer's disease. Neuropsycologia. 2005;43:1824-1837. doi:10.1016/j.neuropsychologia.2005.01.018.

      LeDoux J. The emotional brain, fear, and the amygdala. Cell. Mol. Neurobiol. 2003;23(4-5):727-738. doi:10.1023/A:1025048802629.

      Luzzi S, Piccirilli m, Provinciali L. Perception of emotions on happy/sad chimeric faces in Alzheimer's Disease: Relationship with cognitive functions. Alzheimer Dis. Assoc. Disord. 2007;21(2):130-135. doi:10.1097/WAD.0b013e318064f445.

      Maren S. Building and burying fear memories in the brain. Neuroscientist. 2005;11(1):89-99. doi:10.1177/1073858404269232.

      Ohman A. The role of the amygdala in human fear: automatic detection of threat. Psychoneuroendocrinology. 2005;30(10):953-958. doi:10.1016/j.psyneuen.2005.03.019.

Mouth Care Protocol

      American Dental Association. Oral health topics: dentures. Accessed 2010/02/23/.

      American Dental Association. Cleaning your teeth and gums (oral hygiene). Accessed 2010/02/23/.

      Chalmers J, Johnson V, Tang JH, Titler MG. Evidence-based protocol: oral hygiene care for functionally dependent and cognitively impaired older adults. J. Gerontol. Nurs. 2004;30(11):5-12.

      Gil-Montoya JA, de Mello AL, Cardenas CB, Lopez IG. Oral health protocol for the dependent institutionalized elderly. Geriatr. Nurs. 2006;27(2):95-101. doi:10.1016/j.gerinurse.2005.12.003.


Interventions to Reduce Care-Resistant Behavior

      Beck C, Heacock P, Mercer SO, Walls RC, Rapp CG, Vogelpohl TS. Improving dressing behavior in cognitively impaired nursing home residents. Nurs. Res. 1997;46(3):126-132. doi:10.1097/00006199-199705000-00002.

      Burgener SC, Jirovec M, Murrell L, Barton D. Caregiver and environmental variables related to difficult behaviors in institutionalized, demented elderly persons. J. Gerontol. 1992;47(4):P242-249.

           Burnham H, Hogervorst E. Recognition of facial expressions of emotion by patients with dementia of the Alzheimer Type. Dement. Geriatr. Cogn. Disord. 2004;18:75-79. doi:10.1159/000077813.

        Chalmers JM. Behavior management and communication strategies for dental professionals when caring for patients with dementia. Spec. Care Dentist. 2000;20(4):147-154. doi:10.1111/j.1754-4505.2000.tb01152.x.

        Chalmers JM, Levy SM, Buckwalter KC, Ettinger RL, Kambhu PP. Factors influencing nurses' aides provision of oral care for nursing facility residents. Spec. Care Dentist. 1996;16(2):71-79. doi:10.1111/j.1754-4505.1996.tb00837.x.

      Chalmers J, Pearson A. Oral hygiene care for residents with dementia: a literature review. J. Adv. Nurs. 2005;52(4):410-419. doi:10.1111/j.1365-2648.2005.03605.x

      Herman R, Williams KN. Elderspeak's influence on resistiveness to care: Focus on behavioral events. Am. J. Alzheimers Dis. Other. Demen. 2009;24(5):417-423. doi:10.1177/1533317509341949.

      Mahoney EK, Hurley AC, Volicer L, et al. Development and testing of the Resistiveness to Care Scale. Res. Nurs. Health. 1999;22(1):27-38. doi:10.1002/(SICI)1098-240X(199902)22:1<27::AID-NUR4>3.0.CO;2-T.

      Sloane PD, Hoeffer B, Mitchell CM, et al. Effect of person-centered showering and the towel bath on bathing-associated aggression, agitation, and discomfort in nursing home residents with dementia: a randomized, controlled trial. J. Am. Geriatr. Soc. 2004;52(11):1795-1804. doi:10.1111/j.1532-5415.2004.52501.x.

      Somboontanont W, Sloane PD, Floyd FJ, Holditch-Davis D, Hogue CC, Mitchell CM. Assaultive behavior in Alzheimer's disease: identifying immediate antecedents during bathing. J. Gerontol. Nurs. 2004;30(9):22-29; quiz 55-26.

      Williams KN, Herman R, Gajewski B, Wilson K. Elderspeak communication: impact on dementia care. Am. J. Alzheimers Dis. Other. Demen. 2009;24(1):11-20. PMCID:PMC2823803. doi:10.1177/1533317508318472.

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Other Intended Learner Audiences: 
Estimated time to complete: 
30 minutes
Conflict of Interest Disclosure: 
No, I (we) have nothing to disclose.
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Suggested Citation:
Dr Rita Jablonski. Oral Hygiene & Care-resistant Behaviors: Making a Difference. POGOe - Portal of Geriatrics Online Education; 2011 Available from: