A review of the evidence and best practice for mouth care, looking at its effects on patient health and nutrition, and the risk factors associated with poor oral hygiene
Malkin, B. (2009) The importance of patients’ oral health and nurses’ role in assessing and maintaining it. Nursing Times; 105: 17, early online publication.
Oral hygiene is undervalued in terms of its effects on patient health and nutrition. Effective oral care reduces infection and promotes health. This article explores the evidence for appropriate assessment of oral health and provides guidance for effective oral care.
Keywords: Oral care, Assessment, Guidelines
- This article has been double-blind peer-reviewed
Bridget Malkin, MA Ed, BSc, RNT, RN, is senior lecturer in clinical skills, Birmingham City University.
- Good oral health is important for patients’ health and well-being and should be a priority.
- Nurses should be aware of risk factors associated with poor oral health and be able to assess and help patients maintain oral hygiene.
- A thorough assessment should be done and documented on admission or initial contact, with necessary interventions identified.
- Mouthwashes, toothbrushes and floss should be used where appropriate for oral cleaning and dentures should be taken care of. Treatment for infection and saliva replacement for dry mouths should be initiated when needed.
Oral care is important for patients’ health and well-being for a variety of reasons. Not only is the mouth vital for eating, drinking, taste, breathing, verbal and non-verbal communication, saliva also has antibacterial properties and is part of the body’s defence against infection.Poor oral hygiene is well known to be associated with painful, unpleasant diseases such as gingivitis (Fig 1), dental caries, halitosis and xerostomia and, more recently, has been linked to chest infections and pneumonia (Ministry of Health, 2004). Box 1 gives a glossary of oral terms.
Box 1. Glossary of oral terms
- Cheilitis– reddened, crusting or bleeding area.
- Debris– dead, diseased or damaged tissue and any foreign material that is to be removed from a wound or other area being treated.
- Dental caries – a plaque-induced disease caused by the complex interaction of food, especially starches and sugars, with bacteria that form dental plaque.
- Dental plaque – a biofilm composed of microorganisms that attaches to the teeth and causes dental caries and infections of the gingival tissue.
- Gingivitis– a condition in which the gingival margin around the teeth may be red, swollen and bleeding.
- Halitosis– offensive breath commonly caused by poor oral hygiene, dental or oral infections.
- Oral candidiasis – also known as oral thrush, this common fungus can become prevalent when the natural fauna and flora of the body are unbalanced (Fig 2, image attached).
- Oral hygiene – the condition or practice of maintaining the tissues and structures of the mouth in a healthy state.
- Stomatitis– inflammation of the oral cavity with or without ulceration.
- Tartar– hardened plaque adhered to teeth.
- Xerostomia - dryness of the mouth caused by reduced saliva secretion.
The Essence of Care (Department of Health, 2001) highlighted oral hygiene as a priority, acknowledging it as an indicator of the standard of patient care. The importance of oral care for good communication and nutrition should not be underestimated.
Nutrition is one of the key skills highlighted in the essential skills clusters (NMC, 2007). Assessing factors that influence patients’ nutritional state are key objectives for improving care, although oral care is not specifically identified. However, oral problems can lead to reduced dietary intake and increase the possibility of malnutrition (World Health Organization, 2007).
Inadequate oral care can be detrimental to social and emotional well-being and adversely affect interaction with others (Rawlins and Trueman, 2001). Poor oral hygiene also increases the risk of infection (British Society for Disability and Oral Health, 2000). This risk is often significantly underestimated, resulting in lower priority for oral care compared with other nursing activities (Furr et al, 2004).
In 2007, 50% of UK adults attended an NHS dentist. Older people in residential care are at considerable risk of oral infection, with infection identified in 80% of one study population (Nicol et al, 2005). There are indications that 69% of adults may have periodontal disease (Xavier, 2000). With current regional dental attendance ranging from 40% in southern areas to 60% in the North East (DH, 2007), it is reasonable to assume that many patients might have pre-existing poor oral health before contact with health services.
A healthy mouth
Oral health is defined by the WHO (2007) as: ‘Being free of chronic mouth and facial pain, oral and throat cancer, oral sores, birth defects such as cleft lip and palate, periodontal (gum) disease, tooth decay and tooth loss, and other diseases and disorders that affect the mouth and oral cavity.’
The mouth’s primary functions are the mastication of food and communication, both of which involve the lips, tongue and teeth or dentures and need adequate salivation (Rawlins and Trueman, 2001). In a healthy mouth, oral mucosa and the tongue should be pink and moist, with smooth and moist lips and clean teeth or well-fitted dentures. Difficulties with swallowing or eating may make it hard to maintain the mouth’s healthy condition, as build-up of debris can alter its pH and inadequate dietary intake can reduce salivary flow.
Saliva is essential for keeping oral infections at bay. Its protective, antibacterial properties maintain a healthy balance of resident bacteria, which include Staphylococcus and Candida, and it is also responsible for washing away debris and food particles (Cooley, 2002).
Inflammation and infection can occur as a result of reduced saliva production, with the accumulation of debris forming plaque on teeth at the gum line, which leads to gingivitis, dental caries or periodontal disease. The process decalcifies teeth leaving microscopic crevices that can harbour pathogenic organisms, which can lead to abscess formation (Xavier, 2000).
Oral infections can present as sore, reddened areas or swelling. Fungal infections often present as creamy white coatings or yellow curd-like mounds that are easily removed, sometimes leaving bleeding areas that quickly become recoated (Arkell and Shinnick, 2003). Patients can complain of soreness or difficulty swallowing and are at risk of systemic fever if the infection remains untreated.
Certain medications and predisposing conditions can put patients at increased risk of poor oral hygiene. Dependent, dysphagic, critically or terminally ill people are particularly vulnerable (BSDOH, 2000).
Older people and very young children may have difficulty managing their own oral care due to problems with dexterity, as well as being unable to tell their carer when they are in pain. Additionally, denture wearers are at increased risk of chronic atrophic candidosis (denture stomatitis) as the acrylics within the dentures provide favourable conditions for Candida albicans (Arkell and Shinnick, 2003).
Those with mental health problems may not have an awareness of the need or importance of oral care and may also be unable to express to health professionals when they have problems.
Inadequate dietary intake reduces the secretion of saliva, while a lack of sufficient vitamins and minerals can predispose patients to infection (BSDOH, 2000) and malnutrition.
Immunosuppression related to conditions such as HIV, leukaemia, diabetes and cancer and their associated treatments, including radiotherapy, can impact on hydration and natural flora of the oral cavity, putting patients at risk of infection or malnutrition. Dehydration or the absence of oral intake will reduce the protective production and function of saliva (xerostomia).
Medicines that can alter the fauna and flora of the oral cavity by reducing protective salivary secretion include:
- Analgesics – particularly opiate based.
Medicines that suppress the immune system include:
- Steroid therapy;
Oxygen has been noted to have a drying effect on the mucosa.
Learning and physical disabilities
Some patients may be unable to carry out oral care or express their problems with it (Bollard, 2002). Medications given in syrup form, in addition to a tendency to mouth breathe, can result in dental caries and xerostomia. Those with severe and profound learning disabilities may have behavioural problems with biting that make their oral hygiene difficult to maintain (Bernal, 2005).
Unconscious, intubated patients
The oropharynx of critically ill patients becomes colonised with potential respiratory pathogens (Furr et al, 2004). This study said oral care had been shown to reduce oropharyngeal bacteria and ventilator-associated pneumonia.
Mouth breathing is common in unconscious patients, putting them at risk of xerostomia.
The purpose of oral care should be to keep the lips and mucosa soft, clean, intact and moist. Cleaning the mouth and teeth (including dentures) of food debris and dental plaque should alleviate any discomfort, enhance oral intake and prevent halitosis (Fitzpatrick, 2000). These activities should also prevent oral infection, although treatment for this may be required (Arkell and Shinnick, 2003).
Assessment is needed to identify and initiate interventions and evaluate progress. This requires an understanding of related anatomy and physiology yet there appears to be a lack of nursing knowledge about oral care (Evans, 2001). Assessment can also be hindered by reluctance and nurses’ perceptions about oral care (Clay, 2000).
Several assessment tools have been proposed but evidence is limited on their effect (Cooley, 2002). The Jenkins oral calculator (1989) includes identification of at-risk patients; however, the interpretations are subjective, which can influence the tool’s validity and reliability.
White (2000) identified that the state of the oral mucosa, teeth, inner and outer surface moistness as well as lip softness should be recorded. These are consistent with other oral assessment tools (Eilers et al, 1988) and these observation details are included in Xavier’s (2000) tool adaptation. Lockwood’s (2000) oral assessment tool combined less specific oral structure assessment than other tools and omitted speech ability but included quite specific details with grading on many of the risk factors.
Vocal assessment and swallowing reflex were incorporated into Eilers’ (1988) tool, although nurses are not usually involved in these assessments as patients are commonly referred to speech and language therapists. Nutritional assessment occurs during most admission procedures and many trusts use the Malnutrition Universal Screening Tool (MUST). This tool, designed by the British Association for Parenteral and Enteral Nutrition, includes a swallowing assessment for ability to maintain oral intake (Elia, 2003). The ability to assess swallowing is a required outcome in the essential skills cluster for nutrition (NMC, 2007) and linking the oral assessment to this would provide a holistic model of care.
The consistent application and use of tools in nursing practice has frequently been reported as problematic (Perry, 2009). Applying assessment tools in oral care must be consistent to improve reliability and validity but this will only occur with staff education in their use.
Inadequate assessment and poor knowledge leads to uninformed choice of equipment and techniques in oral care (Evans, 2001). On the other hand, early assessment and intervention reduces the incidence of infection and oral complications (Ministry of Health, 2004) and oral assessment should occur on admission or initial referral (DH, 2001).
The evidence for clinically effective oral care is available (Bowsher et al, 1999) but implementation depends on proper assessment.
An initial assessment should include clarifying with patients or carers:
- History of previous dental care;
- Previous oral problems;
- Patient age and other risk factors such as dentures;
- Current nutritional status;
- Current treatment and any proposed regimen, including medications, radiotherapy and surgery;
- Usual oral hygiene practices.
Gloves and aprons must be worn during physical assessment and oral hygiene procedures, in accordance with infection-control policies.
A visual examination of the oral cavity should be done with patients’ consent. A pen torch, tongue depressor and gauze swab are needed to clearly identify the structures and any abnormalities. Practitioners should record systematic observations and the status of the structures in patient notes (Xavier, 2000). Familiarity with the oral cavity’s structures will enable assessors to identify any abnormalities.
The voice changes in response to infection and dryness. Patients’ voice should be listened to and assessed as:
- ‘Normal’ for the patient;
- Deep or raspy (hoarse);
- Patient has difficulty talking or experiences pain.
A visual assessment of patients’ ability to swallow should be done to determine if it is:
- ‘Normal’ for the patient;
- There is pain on swallowing;
- They are unable to swallow.
Timing of oral care
There is a lack of evidence and consensus about the frequency of oral care to provide maximum benefit for patients (Evans, 2001). However, plaque build-up and gingivitis have been identified in healthy gums 2-4 days after stopping oral care (Pearson and Hutton, 2002).
Adair et al (2001) recommended tooth-brushing twice a day and it is recognised that doing this after every meal reduces infections (Furr et al, 2004). However, Adachi et al (2002) reported significantly reduced infection rates with once-weekly professional oral care.
Factors such as dehydration, mouth breathing and oxygen therapy should increase the frequency of oral care to maintain patients’ comfort and reduce further risk (Cooley, 2002). Maintaining patients’ usual hygiene regimen as a minimum appears to be best practice (Rawlins and Trueman, 2001). But this depends on their usual practice – current British Dental Association (2009) recommendations are for twice-daily brushing.
Box 2 outlines oral care best practice.
Box 2. Best practice
- Daily assessment – identify all risk factors and status of all oral structures, including voice and swallowing.
- Plan oral hygiene with patients if possible.
- Twice daily brushing with toothbrush and fluoride toothpaste.
- Floss if assessment indicates it is safe to do so.
- Use antiseptic mouthwashes twice daily between brushing.
- Use water-based mouthwashes after oral intake.
- Ensure frequent oral fluid intake if condition allows.
- Consider using saliva replacement for dry mouths.
- Keep lips supple and moist with paraffin or lip salve.
- Ensure denture care includes brushing with toothpaste and the use of proprietary dental cleaners.
- Document oral care for evaluation.
Antiseptic mouthwashes are effective antibacterial agents but prolonged use may cause reversible staining of the teeth and adversely affect the natural microorganisms in the oral cavity (Rawlins and Trueman, 2001). They are effective when used twice daily (Bowsher et al, 1999), however they can sting and patients may not tolerate them as well as other types.
Water-based mouthwashes may be better tolerated and these are effective for debris removal from teeth and the oral cavity, and some studies support their use as antiseptic agents (Knox et al, 2000). However, earlier studies identified their ineffectiveness in plaque removal (Kite and Pearson, 1995).
Saline mouthwash is beneficial for mucosal granulation and healing with reduced oral infections (Cheng et al, 2002), although this evidence is limited. The taste of both antiseptic and saline mouthwashes may be unpleasant for patients. Mouthwashing should be done after eating or oral intake (Cooley, 2002).
A small, soft toothbrush will remove plaque and debris from the surfaces and crevices of teeth with minimal gingival trauma, even when a person is unable to brush their own teeth (Pearson and Hutton, 2002). Some electric toothbrushes are more effective at removing plaque than standard brushes. Electric toothbrushes are suitable for those patients with insufficient dexterity to manage a manual brush or inadequate technique. They may also be suitable for people whose hygiene is difficult to maintain such as those with learning disabilities (Bernal, 2005).
Removing debris from the gaps between teeth is effective in reducing build-up of plaque and reducing the likelihood of gingivitis (BDA, 2009). However, caution is needed for those with bleeding tendencies as there is an increased risk of haemorrhage associated with this technique.
Fluoride prevents dental caries by protecting gums and teeth and toothpastes containing this should be used. A pea-sized amount is sufficient (BDA, 2009).
Finger/forcep and gauze
Finger/forcep and gauze cleansing is not effective (Holmes, 1996) and the scrubbing action is likely to be traumatic to oral tissues. This method also puts nurses at risk of being bitten by patients.
These are also ineffective for removing plaque (Pearson and Hutton, 2002) and present a significant choking risk to patients when moistened before use (Department of Health, Social Services and Public Safety, 2008). They have been used for moisture delivery with unconscious patients or where patients’ medical condition increases their risk of bleeding from the gingiva, but their ineffectiveness and risk to patients should be considered.
Oral cavity moisturisers
Sucking ice chips or pineapple is advocated for alleviating the dry mouth that patients frequently experience with a variety of treatments (Clay, 2000). Replacement saliva substitute is advocated for dry mouth xerostomia, but not in excessive volume (Bowsher et al, 1999). Although this replaces moisture it does not provide the antibacterial properties of natural saliva.
Cracked, dry lips are a risk for infection and affect speech ability. Moisturising them maintains integrity and function. The use of soft paraffin or lip salve is effective for this (Cooley, 2002).
Sodium bicarbonate or hydrogen peroxide mouthwashes need specialist administration and should not be considered in routine oral care.
There is a substantial evidence base indicating that glycerine products, including glycerine and lemon swabs, are detrimental to oral care (Rawlins and Trueman, 2001). Detrimental effects include: increased alkalinity; decalcification of teeth; adverse effects to oral mucosa and microorganisms; and the loss of saliva due to over-stimulation by glycerine and lemon mix.
Well-fitted dentures are essential for speech and oral intake. There is significant increased risk of infection from poorly fitted dentures, which can chafe the gums and harbour debris (Fitzpatrick, 2000).
Once-daily cleansing by toothbrush is effective for cleansing dentures using toothpaste. Soaking overnight or when not worn, in commercial denture cleaners, will help prevent infection (Johnson and Chalmers, 2002). Daily replacement of cleansing fluids is necessary to prevent contamination by bacteria such as Pseudomonas. Drying dentures before reinsertion helps to reduce yeast infections such as Candida.
Equipment used incorrectly will not cleanse teeth or dentures effectively. The technique for brushing teeth effectively includes going up and down in parallel with teeth to remove debris from crevices, as well as brushing over the grinding surfaces (BDA, 2009).
Patients’ oral care requirements, as identified during assessment, should drive the selection of appropriate evidence-based tools and equipment for interventions. Careful consideration of patients’ needs and underlying conditions is needed. Reassessment should take place with changes in medication or patients’ condition.
Oral care practices are effective in reducing infection and as such should be given higher priority. Although oral assessment and care are not specific within the essential skills clusters (NMC, 2007), the document implies they influence patients’ nutritional welfare.The Essence of Care (DH, 2001) clearly identified oral assessment and interventions as requirements in patient hygiene. The assessment of factors that influence oral hygiene should be recorded in patients’ notes and evidence-based care initiated to maintain, promote or treat oral hygiene risk factors.
Oral care for neonates, children and those with underlying oral pathologies, post maxillo-oral surgery and in those with bleeding tendency, need specialist consideration beyond the scope of the evidence presented in this article.
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