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Mouth Care by GEMS State and Hand-Under-Hand Brushing

Brushing teeth is not a simple task—it can involve 36 to 42 separate shifts in wrist and hand position, and for someone living with dementia, each step can feel overwhelming or confusing. Hand-under-hand brushing is a gentle way to tap into the person's procedural memory, the automatic movements they have done thousands of times, so they can still participate and feel in control. This article walks you through how to adjust oral care for each GEMS state, using hand-under-hand techniques, with concrete steps, phrases to say, and tools to make the task less stressful for both of you.

Key points

  • Hand-under-hand brushing preserves the person's sense of control and taps into procedural memory, making mouth care less stressful.
  • Adjust your approach based on the GEMS state: Sapphire/Diamond need cues; Emerald needs hands-on guidance; Amber/Ruby need swabs or very gentle brushing.
  • Never grab the person's hand from above—it triggers a reflex to resist. Always slide your hand under theirs.
  • Use a child's soft-bristled toothbrush and non-fluoride toothpaste if swallowing is a concern.
  • If the person resists, pause, change location, or try a different time of day. Forcing leads to long-term resistance.
  • Consistency in caregiver and routine builds trust and reduces anxiety over time.

Why mouth care becomes so hard in dementia

Brushing teeth is not a simple, single action—it is a complex sequence that requires recognizing the need to brush, gathering supplies, squeezing toothpaste onto a brush, moving the brush through dozens of wrist and hand shifts to clean all surfaces of teeth and tongue, then rinsing and drying. For someone with dementia, the brain's ability to plan, sequence, and execute these steps is progressively damaged. What used to be automatic now feels foreign, and the person may resist because they do not understand what is being asked or feel invaded when someone tries to take over. Hand-under-hand brushing works because it bypasses the damaged parts of the brain and taps into procedural memory—the deep, automatic movements stored in the cerebellum. When you place your hand under theirs and guide the brush together, you are not forcing them; you are reactivating a familiar pattern they have done for decades.

How GEMS states change the approach

The GEMS model (by Teepa Snow) describes dementia progression using gemstone names: Sapphire (early, independent), Diamond (still fairly high-functioning but needing cues), Emerald (moderate, needs more hands-on help), Amber (late, very limited ability), Ruby (end-stage, often bedbound). For mouth care, the key is to match your help to the person's current ability. In Sapphire and Diamond states, you might only need to set out supplies and give verbal reminders. In Emerald, you will likely need to do hand-under-hand brushing for most of the process. In Amber and Ruby, the person may not be able to hold a brush at all, so you will use mouth swabs or a very soft brush with gentle guidance. The goal is always to let them do as much as they can for as long as possible—once you take the brush fully out of their hand and brush for them, they rarely regain that skill.

Why hand-under-hand is different from hand-over-hand

Many caregivers instinctively use hand-over-hand—gripping the person's hand from above to control the brush. But this triggers a reflex: when someone grips the back of your hand, you naturally want to pull away or resist. It feels controlling and uncomfortable. Hand-under-hand, on the other hand, places your hand underneath theirs, so you are supporting and guiding rather than gripping. This feels safer and more collaborative. The person still has a sense of control because their hand is on top, and your gentle pressure from below helps them move the brush to the right spots. It also allows you to feel their movements and adjust your guidance in real time.

General caregiving information, not medical advice. Check medications and major care changes with your clinician.

Step-by-step

  1. Set up outside the bathroom if needed. The bathroom can feel cold, bright, or confusing. Choose a comfortable spot—a kitchen table or living room chair—and gather everything you need: a soft-bristled child's toothbrush (easier to handle), toothpaste (a pea-sized amount, or skip it if swallowing is a concern), a towel, a cup of water, and a bowl for spitting. Lay them out in order of use.

  2. Approach the person calmly and say something like, 'It's time to freshen up our teeth. Let's do this together.' Use a warm, matter-of-fact tone. Avoid asking 'Do you want to brush your teeth?' because they may say no. Instead, make it a shared activity.

  3. If the person is in a Diamond or Emerald state, hand them the toothbrush first. Let them hold it. If they seem unsure, place the brush in their hand and then place your hand under theirs, palm up, so your fingers curl gently around the handle beneath their grip. Your hand is the support; their hand is the leader.

  4. Guide the brush to their mouth using your hand under theirs. Start with the front teeth, using small circular motions. Say, 'Let's brush the fronts, nice and gentle.' Move slowly to the sides, then the backs. Remember that each surface requires a different wrist angle—your hand under theirs can help them shift position without forcing it.

  5. If the person resists or clamps their mouth shut, pause. Do not force the brush in. Instead, try a different approach: offer them a sip of water, or let them hold the brush while you gently stroke their cheek or chin to relax the jaw. Sometimes singing a silly song or counting out loud ('One, two, three, four!') can distract and re-engage them.

  6. For the tongue and roof of the mouth, use a very gentle touch. Many people with dementia find this ticklish or unpleasant. If they tolerate it, guide the brush lightly. If not, skip it and focus on the teeth—something is better than nothing.

  7. If the person can spit, offer the bowl and say, 'Spit here.' If they swallow the toothpaste, do not scold them. Use a non-fluoride or baking-soda toothpaste (after consulting their dentist) to reduce risk. Rinsing is optional; if they cannot rinse, a sip of water is fine.

  8. After brushing, let them hold the brush for a moment longer to maintain a sense of control. Then say, 'All done! Great job.' Wipe their mouth and chin with the towel, and offer a small reward—a sip of juice, a hug, or a few minutes of a favorite activity.

  9. If the person is in Amber or Ruby state and cannot hold a brush at all, use a soft mouth swab (like a Toothette) dipped in water or a non-alcohol mouth rinse. Use hand-under-hand by placing their hand on top of yours as you gently swab their gums, cheeks, and any remaining teeth. This still gives them a sense of participation.

  10. For dentures: remove them after meals and at night. Soak them in a denture cleaner. Use hand-under-hand to guide their hand to hold the denture while you both rinse it. If they resist, do it yourself while explaining each step: 'I'm going to take your denture out now, then we'll clean it together.'

What not to do

  • Do not grab the person's hand from above (hand-over-hand). This triggers a reflex to pull away and makes them feel controlled. Instead, slide your hand under theirs to guide gently.

  • Do not try to brush all surfaces at once if the person is overwhelmed. If they only tolerate the front teeth, that is a win. You can try the sides later or at the next session. Forcing all 36–42 steps at once leads to resistance and stress for both of you.

  • Do not use a hard-bristled adult toothbrush. It can hurt sensitive gums and increase resistance. A child's soft-bristled brush is smaller, gentler, and easier to maneuver in a small mouth.

  • Do not ask 'Do you want to brush your teeth?' if you know they will say no. Instead, make it a non-negotiable part of the routine: 'Time to brush our teeth. Let's do it together.' Use a cheerful, matter-of-fact tone.

  • Do not rush or show frustration. If you feel stressed, take a deep breath and try again in 10 minutes. Rushing makes the person feel pressured and less cooperative. Consistency and calmness build trust over time.

  • Do not assume that because the person has no teeth, they do not need mouth care. Gums, tongue, and palate still need gentle cleaning to prevent infections and discomfort. Use a soft swab or brush on gums and tongue.

Practical tools

  • Hand-under-hand setup phrase

    Say: 'I'm going to help you hold the brush. Let's do it together.' Then place your hand under theirs, palm up, and curl your fingers around the handle. This gives them the sensation of holding the brush while you control the movement.

  • Child's soft-bristled toothbrush with a long handle

    A child's brush is smaller, softer, and easier to grip. Look for one with a long, thick handle (or add a foam tube to make it easier to hold). This reduces the number of wrist shifts needed and feels less invasive.

  • Baking soda toothpaste or non-fluoride paste

    If the person tends to swallow toothpaste, switch to a baking-soda-based paste or just water. Fluoride can upset the stomach if swallowed. Always consult their dentist or doctor before changing toothpaste, especially if they have swallowing difficulties.

  • Mouth swabs (Toothette) for Amber/Ruby states

    These are small foam swabs on a stick, pre-moistened or dipped in water. Use them with hand-under-hand: place the person's hand on top of yours as you gently swab gums, cheeks, and any teeth. They are less threatening than a brush and can be used even if the person cannot open wide.

  • A towel and a bowl for spitting

    Place a towel over the person's chest to catch drips. Offer a small bowl for spitting. If they cannot spit, just let the toothpaste foam drip into the bowl or onto the towel. Avoid using the sink if it causes confusion or anxiety.

  • A consistent routine and same caregiver

    Try to have the same person help with mouth care each time. Consistency reduces anxiety. Share notes with other caregivers about what works and what doesn't. If possible, do mouth care at the same time each day (e.g., after breakfast and before bed).

Discuss with your clinician

If the person has a history of swallowing difficulties or choking, ask their doctor or speech therapist if it is safe to use toothpaste or mouth rinse, and whether a non-fluoride paste is recommended.

If the person has bleeding gums, sores, or signs of infection (redness, swelling, pus), consult a dentist before continuing any mouth care routine.

If the person is on blood thinners (e.g., warfarin, apixaban), ask their doctor if gentle gum brushing is safe, as it may cause bleeding.

If the person has dentures that do not fit well or cause pain, see a dentist for an adjustment before trying to clean them.

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