First Issued Issue Version One Purpose of Issue/Description of Change Planned Review Date To promote effective oral hygiene in the community 2014 Named Responsible Officer:- Approved by Date Quality, Governance, and Compliance Service ( Specialist Experts Dental Health ) Section: - Ears, Nose, Throat and Eyes ENT N o 03 Clinical Policies and Procedure Group Target Audience Community Nursing April 2011 UNLESS THIS VERSION HAS BEEN TAKEN DIRECTLY FROM THE TRUST WEB SITE THERE IS NO ASSURANCE THIS IS THE CORRECT VERSION
CONTROL RECORD Title Procedure for Mouth Care Purpose To promote effective oral hygiene in the community Author Quality, Governance and Compliance Service (QGCS) Impact Assessment Completed Yes No Actions Required Yes No Subject Experts Janet Griffiths Document Librarian QGCS Groups consulted with :- Clinical Policies and Procedures Group, Medicines Management Group Infection Control YES Approved Method of distribution Email Intranet Archived Date April 2011 Location S Drive QGCS Access VERSION CONTROL RECORD Version Number Author Status Changes / Comments Version 1 R/ TC Status New / Revised / Trust Change 2/6
INTRODUCTION Mouth care (oral hygiene) is defined as the scientific care of the teeth and the mouth (Thomas 1997 cited in Marsden 2004) Aims of mouth care: To maintain a standard of oral hygiene to prevent the development of dental caries and periodontal disease To keep the oral mucosa clean, soft, moist and intact to prevent infection and to identify any untoward oral problem which requires further management e.g. gum bleeding or ulceration not responding to routine care. To remove food debris and dental plaque without damaging the gingiva To keep the lips clean, soft, moist and intact To provide guidance for health professionals to alleviate pain and discomfort as prescribed by a dental professional To maintain healthy oral function therefore promote oral intake TARGET GROUP Community Nursing Service RELATED POLICIES Please refer to relevant Trust policies and procedures EQUIPMENT Clean receiver or bowl Paper tissues Small headed toothbrush with soft to medium round headed filaments Fluoride toothpaste, recommend to patients /carers the toothpaste has at least 1350 parts per million fluoride (Department of Health 2007). For prevention of periodontal health toothpaste containing triclosan or with zinc citrate are more effective than fluoride toothpaste alone. Single use disposable non sterile gloves Single use disposable apron Denture pot (if required) Denture soaking solution Single use Petroleum Jelly if required 3/6
PROCEDURE Verbally check the identity of the patient by asking the patients full name and date of birth. Check with carer/family if not able to confirm identity Staff members to introduce themselves Explain and discuss the procedure with the patient and relevant family members/carers. RATIONALE To check correct identity of patient To ensure understanding of the procedure and allow time for patient to ask questions Establish patient has no known allergies, check in patients records and also ask patient/family of any known allergies Explain procedure and obtain informed and valid consent, if patient unable to consent, record procedure as best interest in health care records To reduce allergic reactions To allow the patient / client to make an informed decision and gain co-operation Discuss any preferences with main carer if needed Collect and check all equipment To prevent delays and enable full concentration on the procedure Ensure light source is adequate Decontaminate hands prior to procedure To facilitate ease and accuracy of procedure To reduce the risk of transfer of transient micro-organisms on the healthcare workers hands Apply single use disposable apron To protect clothing or uniform from contamination and potential transfer of microorganisms Apply single use disposable non sterile gloves If patient has dentures, they should be removed and placed in a denture pot Examine the patient s mouth and assess patient s individual needs Use a toothbrush with a small head to give better access to the back of the mouth and with densely packed soft to medium synthetic filaments. (Levine and Stillman-Lowe 2004). Using fluoride toothpaste, gently brush the patient s natural teeth, gums and tongue. Replace toothbrush every three months or sooner if required To protect hands from contamination with organic matter and transfer of micro organisms To facilitate access to underlying tissues The mouth is examined for changes in condition with respect to moisture, cleanliness, infected or bleeding areas, ulcers etc. If white or red patches and oral ulceration present and exist for more than a week refer to dental services. If oral thrush present refer to most appropriate prescriber Removes adherent materials and stimulates the gingival tissues to maintain tone. The fluoride in toothpaste serves to prevent, control and arrest dental caries (Department of Health 2007). Toothpastes with triclosan or Zinc citrate are more effective in prevention of periodontal diseases in adults than fluoride toothpaste alone. 4/6
PROCEDURE Brush inner, outer aspects of the teeth. The biting surfaces of side and back teeth should also be brushed. Use the gentle scrub technique of brushing. Place the filaments of the brush at the neck of the tooth and use short horizontal movements. Emphasis should be on small movements and gentle pressure, and a systematic approach to the cleaning of all surfaces (Levine and Stillman-Lowe 2004). Advise patient /carer to brush teeth twice daily. Clean teeth last thing at night and at least one other time each day (Department of Health 2007) The patient should be discouraged from rinsing their mouth after brushing. It is preferable to spit out the paste and if desired, the mouth rinsed with a little water transferred on the brush (Department of Health 2007) If the patient is unable to rinse and void, advise the patient / carer that non-foaming fluoride toothpaste is recommended. A baby toothbrush can be used if necessary Where patients have xerostomia (dry mouth) apply artificial saliva to the tongue, gums and oral mucosa if appropriate (and prescribed) and continue use of fluoride toothpaste. If artificial saliva has not been prescribed refer to GP for advice Apply a suitable lubricant to the lips, if the patient requires oxygen be aware of the potential fire risk if using Petroleum Jelly Where a patient has evidence of gum inflammation or bleeding a suitable mouth rinse can be offered for short periods of time. Foods to advise patients to avoid if they have a sore mouth: Avoid hot spices, garlic, onion, vinegar and salty food. Keep food moist, add gravies and sauces to food Avoid rough textured food e.g. toast or crisps Cold foods and drinks can be soothing to a sore mouth, frequent sipping of iced water gives the best relief Clean the patient s dentures on all surfaces with denture cleaning paste or liquid soap under running water with a denture brush or toothbrush. RATIONALE Brushing loosens and removes plaque and debris trapped on and between the teeth and gums. This controls plaque and prevents gingival inflammation. (Levine and Stillman- Lowe 2004) Rinsing with water immediately after brushing with fluoride toothpaste reduces the benefit both in relation to the development of new cavities and the prevention of recurrent caries around fillings. (Levine and Stillman-Lowe 2004) To reduce the risk of choking on water / toothpaste To facilitate access to all areas of the mouth and reduce the risk of trauma Sponge sticks are not recommended (Somerville 1999 and Medical Device Alert 2008) Increase comfort and prevent further tissue damage Mouth rinses of 0.2% chlorhexidine are very effective in improving plaque control used in short periods when an individual is unable to clean due to acute problems or incapacity. These foods may irritate the mouth To make swallowing easier These foods can scrape sore areas (Levine and Stillman - Lowe 2004) (National Institute of Dental and Craniofacial Research, 2011) To remove debris and plaque from the denture. Hypochlorite is bactericidal and fungicidal and helps break down the organic matrix of adherent plaque that forms on dentures. (Levine and Stillman Lowe 2004) 5/6
PROCEDURE Rinse the denture and place it in a hypochloritebased soaking solution of the Steradent type (e.g. 1 part Milton to 80 parts water). Hypochlorite is not suitable for metal-based dentures for which special soaking solutions containing alkaline peroxide are available After soaking dentures according to the manufacturers instructions for the soaking agent, the dentures should be brushed and rinsed before being inserted. Soaking alone will not clean dentures and that thorough brushing before soaking is essential. Best practice suggests all dentures should be removed before sleeping. Where this is not practical, patients/carers to be advised that dentures should be removed for at least four hours during the day The roof of the mouth, the gum ridges and tongue should be gently cleaned daily with a soft brush (Levine and Still-man Lowe 2004). Clean and thoroughly dry the toothbrush replace every three months or sooner if needed On completion of the procedure remove and dispose of Personal Protective Equipment (PPE) to comply with waste management policy Decontaminate hands following removal of PPE Document all actions and observations in health care records RATIONALE Hypochlorite can cause bleaching of denture plastic if dentures are soaked for long periods or in hot water (Levine and Still-man Lowe 2004) Removal of dentures allows the soft tissues of the mouth to recover from the denturebearing load and to remove the risk of injury or Candida infection (Levine and Still-man Lowe 2004). Removal of food particles and plaque from the soft tissues. Toothbrushes can harbour bacteria if not cleaned and dried effectively To prevent cross infection and environmental contamination To remove any accumulation of transient and resident skin flora that may have built up under gloves and possible contamination following removal of PPE Ensure compliance with Trust record keeping guidelines REFERENCES AND BIBLIOGRAPHY 1. Dougherty, L. and Lister, S.E. (2008) The Royal Marsden Manual of Clinical Nursing Procedures Seventh Edition. Blackwell Publishing, Oxford 2. NHS (2010) Essence of Care Personal and Oral Hygiene 3. Somerville, R. (1999) Oral care in intensive care setting: a case study. Nursing in Critical Care, 41(1): 7-13 4. Levine, R.S. and Stillman-Lowe, C.R. (2004) The Scientific Basis of Oral health Education. British Dental Association 5. Delivering Better Oral Health (2007). An evidence-based toolkit for prevention. British Association for the Study of Community Dentistry and Department of Health 6. Medicines and Healthcare Products Regulatory Agency (2008) 017. Foam heads of oral swabs may detach. 18 th March. 7. National Institute of Dental and Craniofacial Research (2011) Xerostomia. www.nidcr.nih.gov 6/6