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prevent oral infection

prevent oral discomfort

maintain the mouth in a state of normal function (Jones 1998).

Box 9.8 lists the recommendations for maintaining oral health.

Box 9.8 Factors that maintain good oral health

Eating a healthy diet, particularly limiting sugary foods and drinks to reduce the build-up of plaque (this includes sugar-containing medicines).

Stop smoking; it is known to increase the risk of gum disease and oral cancers.

Limit alcohol consumption; high intake is a known risk factor for oral cancers.

Have regular dental check-ups.

Brush teeth for 2 minutes at least twice daily with a fluoride toothpaste and use floss or an interdental brush to clean areas that are hard to reach.

Look for signs of oral disease; consult a dentist if anything unusual is seen.

Take care in activities such as contact sports where facial injuries can occur.

(DH 2005)

Within a variety of care settings, patients can find themselves at risk of poor oral health. Patients in particular need of assistance or extra care include those with the following problems.

Patients who are nil by mouth (including unconscious or ventilated patients).

Patients who mouth breathe (including those on oxygen therapy or with a nasogastric tube).

Cancer patients receiving radiotherapy to the head and neck or chemotherapy which can directly affect the oral cavity or result in reduced immunity to infection.

Patients having oral surgery or who have traumatic injury to the head and neck.

Older patients.

Patients with diabetes.

Patients unable to maintain their own oral hygiene due to physical disability or psychological disorders which could affect motivation.

Patients with clotting disorders.

Patients taking medication which have dry mouth or gum overgrowth as side-effects.

(Potter and Griffin Perry 2003)

There is a variety of evidence available to support practice, ranging from Cochrane reviews to expert opinion. At the very least, each patient should have a thorough assessment of the oral cavity.

Legal and professional issues

Nurses should provide a high standard of care to patients, based on the best evidence available, ensuring they have the necessary skills (NMC 2008b). Numerous studies have found that nurses feel they lack knowledge and training about providing oral care (Southern 2007). Although a number of training tools are available, the provision of adequate training before and after registration requires further attention (Doyle and Dalton 2008, NHSQIS 2004). As is the case for all procedures, a full explanation must be given to the patient and consent obtained (NMC 2008a).

Preprocedural considerations

Equipment

Toothbrush

The toothbrush is recognized as being the most effective means of removing plaque and debris from the teeth and gums. A small-headed, medium-textured brush is most effective at reaching all areas of the mouth. A gentle scrubbing action is recommended, using small movements with gentle pressure for 2 minutes (Sweeney 2005). The brush should be placed at a 45° angle against the teeth and overlaying the gum edge to allow cleaning of the gingival margin (Jones 1998). Powered toothbrushes have been shown to be as effective as manual toothbrushes and may be easier for patients with limited dexterity to use (Robinson et al. 2005). Aids such as foam handles can also be obtained from the occupational therapist to make a manual toothbrush easier to hold. The toothbrush should be allowed to air dry to reduce bacterial contamination and changed every 3 months or sooner if worn (Hahn and Jones 2000). For patients with a sore mouth, a soft or baby toothbrush can be used. A pea-sized amount of fluoride toothpaste should be used; fluoride is known to have an anti-caries activity and can reduce dentine sensitivity. If toothpaste is too abrasive for a patient whose mouth is painful, water alone can be used (Sweeney 2005).

Foam sticks

The foam stick is one of the most common pieces of equipment used in hospital to provide oral care although it is well known that less plaque is removed than