Open Access Highly Accessed Study protocol

Reducing care-resistant behaviors during oral hygiene in persons with dementia

Rita A Jablonski1*, Ann Kolanowski2, Barbara Therrien3, Ellen K Mahoney4, Cathy Kassab5 and Douglas L Leslie6

Author Affiliations

1 CRNP, The Pennsylvania University School of Nursing, 201 Health & Human Development East, University Park, PA 16802, USA

2 School of Nursing, The Pennsylvania State University, University Park, Pa. 16802, USA

3 University of Michigan School of Nursing 400 North Ingalls Building Room 2162 Ann Arbor, MI 48109-0482, USA

4 William F. Connell School of Nursing, Boston College, 140 Commonwealth Avenue, Chestnut Hill, MA 02467, USA

5 By The Numbers 530 Hartman Road, West Decatur, PA 16878, USA

6 The Pennsylvania State University, College of Medicine, A210 Public Health Sciences Hershey Medical Center, USA

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BMC Oral Health 2011, 11:30  doi:10.1186/1472-6831-11-30

Published: 19 November 2011



Nursing home residents with dementia are often dependent on others for mouth care, yet will react with care-resistant behavior when receiving assistance. The oral health of these elders deteriorates in the absence of daily oral hygiene, predisposing them to harmful systemic problems such as pneumonia, hyperglycemia, cardiac disease, and cerebral vascular accidents. The purpose of this study is to determine whether care-resistant behaviors can be reduced, and oral health improved, through the application of an intervention based on the neurobiological principles of threat perception and fear response. The intervention, called Managing Oral Hygiene Using Threat Reduction, combines best mouth care practices with a constellation of behavioral techniques that reduce threat perception and thereby prevent or de-escalate care-resistant behaviors.


Using a randomized repeated measures design, 80 elders with dementia from 5 different nursing homes will be randomized at the individual level to the experimental group, which will receive the intervention, or to the control group, which will receive standard mouth care from research team members who receive training in the proper methods for providing mouth care but no training in resistance recognition or prevention/mediation. Oral health assessments and care-resistant behavior measurements will be obtained during a 7-day observation period and a 21-day intervention period. Individual growth models using multilevel analysis will be used to estimate the efficacy of the intervention for reducing care-resistant behaviors in persons with dementia, and to estimate the overall efficacy of the intervention using oral health outcomes. Activity-based costing methods will be used to determine the cost of the proposed intervention.


At the conclusion of this study, the research team anticipates having a proven intervention that prevents and reduces care-resistant within the context of mouth care. Long-term objectives include testing the effect of the intervention on systemic illnesses among persons with dementia; examining the transferability of this intervention to other activities of daily living; and disseminating threat reduction interventions to nursing home staff, which may radically change the manner in which care is provided to persons with dementia.

Trial Registration NCT01363258