Oral Hygiene Management ( Adult ) - General

Publication: 24/12/2015  --
Last review: 29/01/2019  
Next review: 03/01/2022  
Clinical Guideline
CURRENT 
ID: 4435 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Please check the patients allergy status, as they may be allergic to Chlorhexidine, and alternative ( Providine iodine) solution will be required.
Be aware: Chlorhexidine is considered an environmental allergen.
Refer to the asepsis guidance.

LTHT Oral Hygiene (Adult) Management Guidance

Key messages

  • Good oral health is the absence of a dry mouth, pain and disease allowing the ability to eat, drink and communicate which is important for dignity and quality of life.
  • Oral conditions are largely preventable through the regular removal of plaque deposits by brushing teeth twice daily1.

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Assess the patient

  • Ask the patient if they have any problems with their mouth or mouth care.
  • Find out how mouth care is usually provided for the patient.
  • Look in the mouth using a pen torch2 and wearing gloves.
  • Record assessment and make an individual plan of care.

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Essential mouth care management

  • Patients with a healthy mouth need to have their teeth brushed at least twice a day with fluoride-containing toothpaste
  • Dentures should be cleaned at least once daily with a denture brush or toothbrush, and soap, or if denture tablets are used, by following product instructions. Dentures should be removed at night, and stored in water, in a labelled denture pot3 (see Table 1 FIG 4). Dentures should not be left soaking overnight in denture cleaning tablets3.
  • Support dependent patients to brush their teeth twice a day:
    • Using their own toothbrush or, if not suitable, using a soft small toothbrush (see Table 1 FIG 2).
    • If at risk of aspiration consider using water or non- foaming toothpaste3.
  • If using a toothbrush is not possible consider using a MC3 (formally known as MouthEze) cleanser (see Table 1 FIG 1). The MC3 cleanser can be used to clean soft tissues of the mouth and remove food debris and dried salvia. MC3 can be re-used with the same patient. To clean the MC3 cleanser place under running water and allow to air dry. Manufacturers recommend that MC3 cleansers should be changed every twelve hours.
  • If the person is unconscious, hourly care is recommended using soft small toothbrush with water or non-foaming toothpaste (see Table 1 FIG 3) to clean the teeth, gums and oral cavities.
    • Consider use of oral suction if ropey secretions are present1.
    • MC3 cleansers are an alternative to toothbrush for cleaning soft tissues of the mouth and a safer alternative to foam swabs3 (If using foam swabs to moisten mouth or remove oral secretions, check that the foam head is firmly attached to the stick before use. Do not leave mouth swabs soaking in liquid prior to use as this may affect the strength of the foam head attachment and risk of choking. Dispose of after single use2,6,7,8).
    • Apply dry mouth gel (e.g. Biotiene® oral balance gel) 2 - 4 hourly when required to the lips, tongue and oral cavities to help keep mouth moist.

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Table 1: Products available from NHS supplies

Product

Order Number

Product

Order Number

FIG 1 : MC3 (formally known as MouthEze)

ILA901

FIG 2: Soft Small Toothbrush 
(Toothbrush basic quality child)

MRA186

FIG 3: Non-foaming Oral hygiene Oralieve mild mint toothpaste *

ILA920
*This product contains proteins extracted from milk so is not suitable if patient has a milk allergy or follows a vegan diet.

FIG 4: Denture storage pot

MRA144 (pot) & MRA145 (lid)

Oral conditions and management

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Dry mouth


Regular essential mouth care is the most important part of management

  • Look for reversible causes:
    • Review medication
    • Consider dehydration/other medical causes
    • If oxygen is in use humidification is helpful
    • Recognise and support patients with anxiety
  • Regular sips of fluid are helpful if the person is able to swallow
  • Consider the use of ice cubes, ice pops, lollies16 (Staff must follow LTHT (2018) Heatwave Plan for procedure regarding use of ice16).
  • Consider chewing gum, to stimulate saliva production, if the patient is able to chew. Gum should be sugar fee and, if the patient wears dentures, low tack.
  • Consider use of artificial saliva (e.g. Biotiene®, AS Saliva Orthana® ).
    • Note some products (e.g. AS Saliva Orthana®) contain mucin from pigs which may be unacceptable to those following a vegetarian diet, or people of Jewish or Muslim faith).
  • Reassess regularly.

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Coated mouth

  • Often caused by inadequate salivary function so associated with dry mouth
  • Manage as for dry mouth
  • Increase frequency of mouth care. Hourly rinsing with water or saline can be helpful
  • Gentle brushing of the tongue with a soft tooth brush several times a day can aide debridement
  • Reassess regularly.

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Sore or ulcerated mouth


Regular essential mouth care is the most important part of management

  • Identify and treat the cause where possible (e.g.  trauma, aphthous ulcers, infection, malignancy, nutritional deficiencies, GI conditions, haematopoietic disorders and drug-induced)
  • Increase frequency of mouth care. Hourly rinsing with water or saline can be helpful
  • A coating agent such as Gelclair®, alcohol free mouthwash can be useful and may help with eating when used 30-60 minutes before meals.
  • Topical NSAID options are
    • Benzydamine Hydrochloride (Diflam®)
    • Choline salicylate (Bonjela®, remove dentures before use/ wait 30 minutes before re-inserting)
  • If not responsive to above measures, consider use of topical anaesthetics and apply directly to painful area e.g. Lidocaine (Xylocaine®) 10% spray applied using cotton bud p.r.n. Avoid anaesthesia to pharynx before meals/drinks.
  • For severe oral pain, consider the combined use of topical and systemic preparations. Seek appropriate specialist advice e.g. dental hospital, Ear, Nose and Throat (ENT) team, acute hospital pain team, hospital specialist palliative care team, pharmacy.
  • Reassess regularly. 

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Oral thrush management


Regular essential mouth care management reduces the chance of infection and should be continued

  • Use a new toothbrush
  • Drug treatment (requires medical review) will improve symptoms,
    •  
      • Note Nystatin and chlorhexidine mouthwash should not be used at the same time, as they will inactivate each other. Use 1 hour apart.
  • For patients with dentures ensure dentures are thoroughly cleaned and soaked in appropriate antiseptic (e.g. chlorhexidine) for 15 minutes then rinsed in water.
  • Dispose of toothbrush following completion of drug treatment.

NB: All medications must be prescribed

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Further information and guidance for oral hygiene management is available from the following documents: LTHT (2015) Oral Hygiene - Protocol for Adult Critical Care Leeds Health Pathways, LTHT (2017) Oral Mucositis- Prevention and Management Guidance for Adult Patient, National Institute for Health and Care Excellence (NICE) Palliative Care - Oral management (revised July 2015). Twycross, R. Wilcock, A. Howard, P (2017) Palliative Care Formulary (PCF6) 6th Edition (UK).

  • All medications must be prescribed
  • When performing mouth care, wash and dry hands thoroughly and wear disposable gloves and apron.
  • For full reference list please refer to LTHT General Oral Hygiene Management (adult) Guidance (2019).
Healthy Mouth
Dry Mouth
Coated Mouth
Sore or Ulcerated Mouth
Oral thrush
Description
Description
Description
Description
Description
  • Patient able to eat without discomfort
  • Lips / Mucous membranes / Tongue smooth, pink and moist
  • Healthy gums are usually pink and firm
  • Healthy gums are usually pink and firm
  • Dentures - fit comfortably

 

  • Dryness of mucus membranes
  • Dryness of lips
  • Impaired taste
  • Difficulty chewing and swallowing
  • Furrowed tongue with deep grooves (fissuring)10,11

‘Coating’ may be on any part of the tongue. The coating may be yellow, brown or black in colour and may cause discomfort and taste changes

The person may be reluctant to eat and drink9
  • Redness of mucus membranes
  • Ulcerated areas on gums, tongue or lips
  • Pain
  • Inability to take food or drink into mouth
  • Difficulty chewing and swallowing

Fungal infection

  • White spots or redness and soreness of the tongue and mucus
    membranes.
  • Cheilitis (soreness, redness and fissures at the angles/corners of the mouth).
  • Pain with difficulty eating and drinking 2,9
Management
Management
Management
Management
Management

Essential mouth care management

  • Patients with a healthy mouth need to have their teeth brushed at least twice a day with fluoride-containing toothpaste

  • Dentures should be cleaned at least once daily with a denture brush or toothbrush, and soap, or if denture tablets are used, by following product instructions. Dentures should be removed at night, and stored in water, in a labelled denture pot3. Dentures should not be left soaking overnight in denture cleaning tablets3.

  • Support dependent patients to brush their teeth twice a day:

  • Using their own toothbrush or, if not suitable, using a soft small toothbrush.
  • If at risk of aspiration consider using water or non- foaming toothpaste3.

    •If using a toothbrush is not possible consider using a MC3 (formally known as MouthEze) cleanser. The MC3 cleanser can be used to clean soft tissues of the mouth and remove food debris and dried salvia. MC3 can be re-used with the same patient. To clean the MC3 cleanser place under running water and allow to air dry. Manufacturers recommend that MC3 cleansers should be changed every twelve hours.

  • If the person is unconscious, hourly care is recommended using soft small toothbrush with water or non-foaming toothpaste (see Table 1 FIG 3) to clean the teeth, gums and oral cavities.

  • Consider use of oral suction if ropey secretions are present1.

  • MC3 cleansers are an alternative to toothbrush for cleaning soft tissues of the mouth and a safer alternative to foam swabs3 (If using foam swabs to moisten mouth or remove oral secretions, check that the foam head is firmly attached to the stick before use. Do not leave mouth swabs soaking in liquid prior to use as this may affect the strength of the foam head attachment and risk of choking. Dispose of after single use2,6,7,8).
  • Apply dry mouth gel (e.g. Biotiene® oral balance gel) 2 - 4 hourly when required to the lips, tongue and oral cavities to help keep mouth moist.

Regular essential mouth care is the most important part of management

  • Look for reversible causes:

  • Review medication
  • Consider dehydration/other medical causes
  • If oxygen is in use humidification is helpful
  • Recognise and support patients with anxiety

  • Regular sips of fluid are helpful if the person is able to
    swallow
  • Consider the use of ice cubes, ice lollies16 (Staff must follow  LTHT (2018) Heatwave plan for procedure for use of ice16).
  • Consider chewing gum, to stimulate saliva
    production, if the patient is able to chew. Gum should be sugar fee and if the patient wears dentures low tac.
  • Consider use of artificial saliva (e.g. Biotiene®, AS
    Saliva Orthana®).

  • Note some products contain mucin from pigs (for example AS Saliva Orthana®) which may be unacceptable to certain groups of people, such as vegetarians, and people of Jewish or Muslim faith).

Reassess regularly.

 

Regular essential mouth care is the
most important part of management

  • Often caused by inadequate salivary function so associated with dry mouth
  • Manage as for dry mouth
  • Increase frequency of mouth care.
    Hourly rinsing with water or saline can be helpful
  • Gentle brushing with a soft tooth brush several times a day can aide debridement
  • Reassess regularly.

Regular essential mouth care is the most important part of management

  • Identify the and treat the cause where possible (e.g. trauma, aphthous ulcers, infection, malignancy, nutritional deficiencies, GI conditions, heamatopoetic disorders and drug induced)
  • Increase frequency of mouth care. Hourly rinsing with
    water or saline can be helpful.
  • A coating agent such as Gelclair®, alcohol free mouthwash can be useful and may help with eating

Topical NSAID options are

  • Benzydamine Hydrochloride (Diflam®)
  • Choline salicylate (Bonjela®, remove dentures before use/ wait 30 minutes before re-inserting).
  • If not responsive to above measures, consider use of topical anaesthetics and apply directly to painful area e.g. Lidocaine (Xylocaine®) 10% spray applied using cotton bud p.r.n. Avoid anaesthesia to pharynx before meals/drinks.
  • For severe oral pain, consider the combined use of topical and systemic preparations. Seek appropriate specialist advice e.g. dental hospital, acute hospital pain team, hospital specialist palliative care team,
  • Reassess regularly.

Regular essential mouth care reduces the chance of infection and should be continued

  • Use a new toothbrush
  • Drug treatment  (requires medical review) will improve symptoms.

  • Note Nystatin and chlorhexidine mouthwash should not be used at the same time, as they will inactivate each other. Use 1 hour apart.

  • For patients with dentures ensure dentures are thoroughly cleaned and soaked in appropriate antiseptic (e.g. chlorhexidine ) for 15 minutes then rinsed in water.
  • Dispose of toothbrush following completion of drug treatment.

Provenance

Record: 4435
Objective:
Clinical condition:
Target patient group:
Target professional group(s): Secondary Care Nurses
Registered Nurses Working in Critical Care
Adapted from:

LTHT: November 2015 Review Date: November 2018
Adapted from South West Yorkshire Partnership Foundation Trust, Barnsley Hospice, Barnsley Hospital NHS Trust, Sheffield Hallam
University and the Independent Care Sector Last days of life: oral hygiene management (2014)


Evidence base

References

  1. Public Health England. (2017) Delivering better oral health: an evidence-based toolkit for prevention. Third Edition
  2. The Royal Marsden (2015) The Royal Marsden hospital manual of clinical nursing procedures. Ninth edition. http://lthweb.leedsth.nhs.uk/sites/nursing-midwifery-and-allied-health-professionals/royal-marsden-manual/royal-marsden-manual
  3. Health Education England (2016) Mouth Care Matters: A guide for hospital healthcare professionals. HEE.
  4. Fallon M and Hanks G. (2006). ABC of Palliative Care. 2nd eds. Oxford: Blackwell,  
  5. Ridley KJ and Pear S (2008) Oral Health Assessment: A neglected component of comprehensive oral care. Healthcare Purchasing News August 2008.
  6. Davies AN, Eptein JB.(2010).  Oral complications of cancer and its management.  Oxford: University Press.
  7. Stout M, Goulding O, Powell  A. (2009).Developing and implementing an oral care policy and assessment tool. Nursing Standard; 23 (49) 42-8.
  8. Pearson L S, Hutton J L. (2002). A controlled trial to compare the ability of foam swabs and toothbrushes to remove dental plaque. Journal of Advanced Nursing; 39 5 480-489.
  9. Davies A, Finlay I (2005) Oral Care in advanced disease. Sweeney P, Author  Oral Hygiene.  Oxford University Press. Oxford.
  10. Joint Formulary Committee. British National Formulary 65. March – September 2013. BNF publications.
  11. Epstein J B, Emerkin S, Stevenson- Moore N D LE, P. (1999). A double blind cross-over trial of oral balance gel and biotene toothpaste versus placebo in patients with seretoma following radiation therapy. Oral Oncology 1999; 35 (2) 132-137.
  12. SPC Xylocaine 10mg Spray. eMC (updated16/4/12) http://www.medicines.org.uk/emc/medicine/205#POSOLOGY (accessed 14/5/13).
  13. Miligan S, McCall M, Sweeney MP, Malarkey C. (2001). Oral care for people with advanced cancer an evidenced based protocol. International Journal of Palliative Nursing; 7 9 418-426.
  14. Krishanasamy  M. (1995). Oral problems in advanced cancer. European Journal; of Cancer Care; 4 (4) 173-177.
  15. Farah C.S., McIntosh, L., & McCollough, M, J. (2009). Mouthwashes. Australian Prescriber 32(6): 162-164.
  16. LTHT (2018) Heatwave Plan Version 7.2 available at http://lthweb.leedsth.nhs.uk/sites/eprr/heatwave-1/LTHT%20Heatwave%20Plan%20V7.pdf/view  page 12 point 15.1

 

Further information and guidance for oral hygiene management is available from the following documents:

LTHT (2015) Oral Hygiene - Protocol for Adult Critical Care Leeds Health Pathways detail.aspx?ID=756

LTHT (2017) Oral Mucositis- Prevention and Management Guidance for Adult Patient, detail.aspx?ID=3124

National Institute for Health and Care Excellence (NICE) Palliative Care - Oral management (revised July 2015).

Twycross, R. Wilcock, A. Howard, P (2017) Palliative Care Formulary (PCF6) 6th Edition (UK)

 

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Not supplied

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