accepted Accepted Added Accepted Accepted Accepted Accepted

Transcription

1 External review Addition of key principles section at start Assessment protocol In assessment Change identify to all patients are and Remove elderly, terminally ill, immuno-compromised, nasogastric or PEG tube fed, Oxygen therapy, dysphagia, oropharyngeal disease, neurodegenerative disorders (e.g. MND, parkinson s Disease), limited manual dexterity Reformat drug history Bisphosphonates change particularly if teeth/gums are in poor condition to Ill fitting dentures and surgical intervention including tooth extraction increase this risk highlighting the need for preventative oral hygiene therapy. Add Ask patients on a daily basis if they are having problems After remove dentures add before examining the mouth or performing routine mouthcare Add Check the lining of the mouth is clean. If not refer to dry/coated mouth protocol. After looking for signs of a dry mouth add with a water based product Added PRACTICE POINT: Previous applications of water based lubricants should be gently removed before replacing. Refer to dry/coated mouth protocol. Look for signs of dryness, coating, ulceration, infection or tooth decay. - Assess for pain had been removed Changes two years to one year accepted Removed the word protocol as these are guidelines. Have changed the word protocol throughout. Legal implications. Each health board may have different protocols etc. Added except change word protocol to care changing protocol to care Re-added assess for pain. Re-ordered to Remove dentures before examining the mouth or performing routine mouthcare Use a torch to thoroughly examine the

2 Management title removed Healthy mouth changed to oral hygiene care Sectioned into all patients, dentate, edentulous (including denture hygiene) reordered some points and changed others into practice points Remove prevent oral infection, tooth decay, halitosis Remove - Oral care using a soft, small-headed toothbrush, fluoride toothpaste after each meal and at bedtime. Spit out but don t rinse with water after brushing if tolerated. And replace with refer to dry/coated mouth care New section Edentulous Patients All dentures should be marked with the patient s name A denture fixative may provide relief from extensive movement of dentures. Dentures should be removed overnight and soaked in a suitable cleansing solution o Dilute sodium hypochlorite solution for plastic dentures. o Chlorhexidene gluconate solution for dentures with metal parts Rinse dentures thoroughly before replacing in the mouth. Remember to check the lining of the mouth is clean. If necessary clean the oral mucosa: refer to dry /coated mouth protocol. Dentures should be checked for cracks, sharp edges and missing teeth daily. mouth Reinstated to section guidance according to template and for ease of finding information Added referral to cahexia guidance re snacks between meals for clarity. This is an aim could be assumed Chemo/radiotherapy added Gelclair is a viscous gel specially formulated to aid in the management of lesions of the oral mucosa. It forms a protective film that, by coating and sticking to the lining of the mouth and Not sure this is different to managing lesions from any other sources and had been already included in the painful mouth section although external reviewer moved. Returning to painful mouth section as it sits most comfortably there along with practice

3 throat, offers rapid and effective pain management. Added Caphosol is a supersaturated calcium phosphate mouthrinse approved for restricted use for the prevention of oral mucositis in patients undergoing radiotherapy for head and neck cancer, and for patients undergoing chemotherapy. Consultation with a haematologist or oncologist is required before prescription. point Dry/Coated mouth care Points reformatted Some points changed to practice points Added in reference to BNF section Changed guidance about removal of debris Removed chlorhexidine information Added varnish Painful mouth care Removed - Assess cause and treat accordingly Added - Consider oral mucositis as a possible cause in patients receiving chemotherapy or radiotherapy. Oral mucositis is a condition characterized by pain and inflammation of the mucous membrane which may present as painful mouth ulceration affecting any or all intra-oral surfaces. Analgesia added after mouthwash - provides no topical effect. Do not advise patients to use this as a mouthwash. Added practice point - PRACTICE POINT: If patient unable to rinse and expectorate or aspiration risk, soak guaze in Chlorhexidine gluconate 0.2% mouthwash and gently wipe over coated surfaces, teeth and gums. Remove Painful mouth with no visible ulcers/small number aphthous ulcers Tabulated this section to make easier to read - in general oral health care section accepted - for role in desensitisation as well as caries prevention added general assessment section at start adding the word particularly before in patients receiving chemo etc Mucositis can be relatively common in immunocompromised patients this population We tend to discourage use of benzydymine

4 Bland mouthwash, eg saline or weak sodium bicarbonate Benzydamine hydrochloride 0.15% (Difflam oral rinse) 15ml, 2-3 hourly for up to 7 days. Dilute 1:1 with water if it stings too much. Painful mouth with multiple aphthous ulcers/mucositis Bland mouthwash, eg saline or weak sodium bicarbonate Coating Agent e.g. Gelclair If symptoms persist, consider sending swab for culture and seek specialist advice. in acutely painful mouths as it's alcohol content can make it incredible painful to use. except expanded Gelclair is a viscous gel specially formulated to aid in the management of lesions of the oral mucosa. It forms a protective film that, by coating and sticking to the lining of the mouth and throat, offers rapid and effective pain management. PRACTICE POINT: The contents of one sachet should be diluted with 40mls of water and used as a mouthwash. This should be repeated three times a day one hour before eating or drinking. Added practice point - PRACTICE POINT: Causes include: trauma (from sharp teeth), haematinic deficiency, viral infection( herpes simplex), aphthous ulceration, oral malignancy& mucositis. Oral infections new heading, grouped and formatted under this heading Fungal infections intro Always check the BNF thoroughly for drug interactions before prescription of antifungal medication. Of note, fluconazole and miconazole should be avoided in patients prescribed warfarin or statins. Changed thrush to candidiasis in introduction Changed this to practice point to make it stand out more. Adding (including topical ) in front of miconazole as this has led to fatal outcomes in patients prescribed warfarin "review and extend as necessary" with regard to fluconazole but we feel it is important to refer for dental opinion if no improvement in 7 days to rule out any other oral cause. We discussed miconazole cream vs gel but chose gel as it can also be used intraorally as practice point. expert opinion- note conflict with Drug Prescribing for dentistry (Scottish

5 and the mouth is very often the reservoir of infection. Miconazole gel is also more palatable. Added - PRACTICE POINT: swab angles, tongue and anterior nares to investigate possible Staphylococcal infection. If present adjust treatment accordingly Nystatin - 1ml very small volume. Very difficult to use as mouthwash. Suggested 5 mls for ease of use however have left at 1ml as per BNF. Removed dentures should be cleaned thoroughly Dental Clinical Effectiveness programme) as 1ml expert opinion on removing this reminder Viral Infections Added - Herpes simplex is the most common viral infection Removed - Treat lip lesions (at prodromal stage if possible) with aciclovir cream 5%; apply 4 hourly (5 times a day) for 5-10 days. Added - Provide supportive therapy: encourage fluid intake, keep mouth moist, apply water based lubricant, anti pyretic medication, & analgesia. This had been the subject of much debate. Depending on the severity of the lesion reduction in even half one day may be a quality benefit to patients. Agreed to leave out. Removed - Acute necrotising ulcerative gingivitis (ANUG) Consider if anaerobic (foul smelling) lesions and/or severe gingivitis with gingival ulceration Treat with oral Metronidazole. 200mg three times daily for 3 days expert opinion. To note the guidance now contains no information about odour management. Excessive drooling Re-ordered points 1 and 2 And added - consider physiotherapy assistance around positional change and/or speech and language therapy around swallowing techniques.

6 Taste Change Changed it is important to keep eating to Maintenance of nutritional intake is essential recognizing this may not be possible within this patient group particularly with disease progression. Realistic goals are important. Added If patients are prescribed build up drinks there is an added mouthcare responsibility. Removed patient carer advice points Unsure why buildup in particular. No more than any other food supplement. Likely to be more about frequent food intake rather than the product itself. rejected. Will add a practice point about greater care with frequent intake above three meals a day. removal of Where possible reduce sugary snacks and drinks especially between meals. (Link to Cachexia Guideline) Brush teeth with a fluoride toothpaste ( ppm) twice a day including last thing at night before bed. Try sugar free chewing gum. Replaced following 3 which are not covered elsewhere in text and added the word additional. Patient/Care Advice Points Register with a dentist and visit regularly A denture fixative may provide relief from excessive movement of dentures. Smoking and alcohol can contribute to oral problems.