Mouth care is part of basic nursing care. It can be defined as the promotion of health and the prevention or treatment of disease of the oral mucosa, lips, teeth and gums (Dougherty et al, 2015). The three mains aims of oral care are assessment, care and patient education (Baillie, 2014).
Rationale for oral care
The Department of Health's Essence of Care document (2010) emphasised that oral hygiene is a priority and a standard facet of patient care. Nurses, who work at the heart of health care, may find themselves as the first point of contact with patients who require assistance with oral care or who are experiencing oral problems (Brooker and Nicol, 2015).
The mouth is the most important part of the face: it is required both for communication and to consume food and drink. It is therefore important to adhere to good oral cavity hygiene, to avoid both of these functions being severely affected (Peate, 2010). Conditions such as xerostomia (dryness of the mouth) can pose complications, such as infection or oral thrush and ulceration (Dougherty et al, 2015).
Poor oral hygiene may result in the following:
Pain and discomfort, which may result in a reduced oral intake
Increased risk of bacteraemia and bacterial endocarditis
Increased risk of sepsis and respiratory infections or halitosis (bad breath), which in turn can affect an individual psychologically (Stout et al, 2009).
Assessment of the mouth
Eilers et al (1988) devised a simple tool for assessing the mouth based on six categories: lips, tongue, saliva, mucous membranes, gingival and teeth (Peate, 2010). Although there are several tools that can be used to assess oral health, evidence is limited on their effectiveness (Brooker and Nicol, 2015). Another tool that can be used to assess the condition of the mouth includes the Oral Health Risk Assessment (OHRA), which can help identify a trauma or fractured teeth, unstable dentures, dry mouth, infections or sores, and complications related to the tongue (British Society of Gerodontology, 2010).
Promoting self-management
Public Health England has outlined several ways in which health professionals can promote oral hygiene in its toolkit Delivering Better Oral Health: An evidence-based toolkit for prevention (2017). These include offering patients advice to brush their teeth at least twice a day with a fluoridated toothpaste—this can be last thing at night and then on one other occasion. Patients should also be advised not to rinse their mouth after brushing, to ensure that fluoride concentration is maintained within the mouth cavity.
Other advice for good oral hygiene includes stopping the use of tobacco (chewed or inhaled) and, in terms of diet, limiting the amount and frequency of sugary food and drinks, limiting alcohol intake and encouraging healthy eating habits (Public Health England, 2017).
When people are healthy, oral care tends to be part of their daily routine; however, those who are ill, ventilated or unable to attend to their own oral hygiene are at risk of poor oral care (Peate, 2010).
The Mouth Care Matters campaign was launched by Health Education England (HEE) in 2018. It stated that care would be more responsive and personalised, with emphasis on the importance of good mouth care and how it may affect quality of life. HEE highlighted that research has found that oral care can be lacking in hospital and community care settings, particularly for those who rely on assistance with their personal hygiene. Some of the evidence has shown that those who have prolonged stays in hospital may be more likely to have poor oral hygiene and complications, which can result in longer hospital stays and increased care costs (HEE, 2018). The UK's ageing population is more likely to be at risk of poor oral hygiene due to a deterioration in physical and cognitive abilities, including dementia (Dementia UK, 2017).
Health Education England has established four key principles in relation to Mouth Care Matters:
Knowledge: provide staff/carers with knowledge about why mouth care is so important
Skills: ensure staff/carers are skilled to provide good mouth care
Access: ensure patients have access to effective mouth care products
Support: ensure staff/carers/patients have support from staff with enhanced oral health skills.
Nursing considerations for providing oral care are set out below.
General oral care
Equipment
The following items will be necessary (Baillie, 2014; Dougherty et al, 2015; Public Health England, 2017):
Plastic apron
Non-sterile disposable gloves
Small torch
Wooden spatula
Gauze (to wipe spillages)
Plastic cups
Appropriate equipment for cleaning, eg foam sticks/toothbrush
Clean receiver or bowl
Paper tissues
Small-headed, soft toothbrush
Toothpaste (fluoride preferred)
Dental floss
Mouthwash (0.2% chlorhexidine)
Lip lubricant (non-petroleum based).
Procedure
Gather the above equipment. Explain procedure, gain consent and encourage independence in carrying out the task
Wash your hands or decontaminate them with the appropriate solutions. Put on plastic apron and disposable gloves
Prepare the mouthwash
Carry out the oral assessment using an oral assessment tool to establish the baseline for monitoring
Using the torch, spatula and gauze inspect the patient's mouth, including teeth, lips and buccal mucosa. Observe the lateral and ventral surfaces of the tongue, floor of the mouth and the soft palate
Ask the patient whether they have experienced any changes with taste, saliva production or composition, and establish if there are any problems such as oral discomfort or problems swallowing
Using a small soft toothbrush and a pea-sized amount of toothpaste, brush the patient's natural teeth, gums and tongue
Hold the toothbrush at a 45° angle, the tips of the outer bristles should touch the gingival sulcus. Move the bristles from side to side with a light pressure to squeeze the gum tissue against the teeth
Repeat this motion around the upper and lower teeth on the outer and inner surfaces
The minimum time that teeth should be cleaned is for 90 seconds
If rinsing is required, ask the patient to rinse their mouth with warm water to remove debris, or use foam sticks moistened with water to sweep away debris and excess toothpaste. Rinsing with a lot of water should be discouraged. Consider using some more toothpaste for the final stages of brushing if toothpaste has been washed away during rinsing. Use minimal amounts of water or chlorhexidine mouthwash after brushing because this may dilute the concentration of fluoride, thereby reducing the protection. Chlorhexidine can be released from the tissues for up to 12 hours and can be used if the patient is unable to brush their teeth. It can help provide plaque build-up but does not remove plaque itself, therefore brushing should be encouraged where possible (Dougherty, et al, 2015)
Floss upper and lower teeth using dental floss, unless contraindicated
Record in appropriate documentation
Rinse toothbrush and allow to air dry. Dispose of foam sticks. Toothbrushes should be replaced every 6-12 weeks
Lip care should be provided at this stage. Lip crusting can be removed using warm water and a sponge. If lips are dry use a non-petroleum based lip lubricant.
Oral care for denture wearers
Equipment
The following equipment will be required (Baillie, 2014; Dougherty et al, 2015):
Plastic apron
Non-sterile disposable gloves
Small torch
Plastic cups
Wooden spatula
Gauze (for wiping spillages)
Appropriate equipment for cleaning, eg foam sticks/toothbrush
Clean receiver or bowl
Denture pot
Denture brush
Paper tissues
Denture paste, soap, soaking solution
Mouthwash (0.2% chlorhexidine)
Lip lubricant (non-petroleum based).
Procedure
Gather the equipment. Explain procedure, gain consent and encourage independence in carrying out the task
Wash your hands or decontaminate them with the appropriate solutions. Put on apron and gloves
Prepare the required solutions
Remove dentures and place them into a denture container
Rinse mouth to get rid of any excess debris
Carry out the oral assessment using an oral assessment tool in order to establish the baseline for monitoring
Using the torch, spatula and gauze inspect the patient's mouth, including any teeth, lips and buccal mucosa. Observe the lateral and ventral surfaces of the tongue, floor of the mouth and the soft palate
Check whether the patient has experienced any changes with taste, saliva production or composition and establish if there are any problems such as oral discomfort or problems swallowing
Using a specific denture brush, scrub all surfaces using a little denture paste or soap to get rid of any debris. Rinse thoroughly with water
Oral care may need to be offered to patients who have both natural and artificial teeth
When dentures are not being worn they may be soaked in water; other solutions include sodium hypochloride for plastic dentures, which can be used 2-3 times per week to prevent oral candidiasis. Rinse thoroughly before placing in the mouth.
Conclusion
This article has outlined the importance of mouth care and discussed some considerations in relation to providing oral care within clinical practice. The role of the nurse in providing an assessment of oral health has also been highlighted, alongside key considerations in relation to maintaining good oral hygiene. It is hoped that this step-by-step guide to providing oral hygiene for both natural teeth and dentures will help nurses in this task.
LEARNING POINTS
Understand the rationale for the importance of mouth care as a fundamental nursing skill
Know the guidelines to follow when providing oral care
Be aware of the equipment and procedure to use when providing mouth care to adult patients
Understand the basics of providing tooth and denture care
Be able to identify some of the oral abnormalities that may present and those that may give cause for concern
