The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [323]
Interdental cleaning
The use of dental floss or other equipment is recommended to clean areas between the teeth which may be difficult to reach with a toothbrush (Huskinson and Lloyd 2009). There is currently limited evidence of the efficacy of flossing although it is generally believed to be beneficial (Berchier et al. 2008). A variety of equipment is available such as dental floss, dental tape, wood sticks or interdental brushes. For patients who have limited dexterity, this may be difficult or impossible to carry out. Similarly, in patients with painful mouths or bleeding gums, this type of equipment could cause further discomfort or bleeding and should be avoided.
Oral irrigation devices such as the WaterPik® can also be used for interdental cleaning. Oral irrigation involves a jet of water being used to remove debris and plaque and can be useful for people who find it difficult to use dental floss or tape such as those with braces. A systematic review of oral irrigation has shown a positive tendency but no overall benefit in reducing plaque over use of a toothbrush alone (Husseini et al. 2008).
Assessment and recording tools
The mouth should be assessed as part of the initial nursing assessment and should be reassessed regularly thereafter (DH 2001, NHSQIS 2004). Frequency of assessment is often based on clinical judgement rather than evidence. For patients at high risk of changes to the condition of the mouth, such as those receiving high-dose chemotherapy, assessment should be carried out daily (Quinn et al. 2008). For elderly patients receiving long-term care, it has been recommended that reassessment takes place monthly (NHSQIS 2004). For certain patients, such as those receiving high-dose chemotherapy or radiotherapy to the head and neck, an assessment by a dentist is recommended prior to starting treatment.
The use of an oral assessment tool is recommended to ensure consistency between assessors and to monitor changes. A number of tools have been devised for different patient groups. Tools such as the WHO scale (WHO 1979) or the Oral Assessment Guide (OAG) (Eilers et al. 1988) are commonly used in assessing patients receiving anticancer treatments. Numerous other tools exist to assess oral mucositis, although some lack evidence of validity and reliability. Use of a validated tool is recommended (DH 2001). Several tools have also been designed to meet the needs of elderly patients and those with dementia (Kayser-Jones et al. 1995, Roberts 2001). The ideal assessment tool should measure:
functional changes, for example ability to talk or eat
physical changes, for example presence of ulcerated areas
subjective changes, for example pain or dryness.
The ideal tool has not yet been developed and it may be necessary to use a combination of tools to make a thorough assessment. Patient education to encourage self-assessment is also recommended (Quinn et al. 2008).
Good assessment is vital before a care plan can be formulated. Assessment should include visual inspection and obtaining a history from the patient. Many factors should be considered when carrying out a full oral assessment (Box 9.9).
Box 9.9 Factors to consider when carrying out an oral assessment
Usual oral hygiene practice and frequency.
Regularity of dental visits.
Oral discomfort or pain.
Dry mouth.
Difficulty chewing.
Difficulty swallowing.
Difficulty speaking.
Halitosis (malodorous breath).
Drooling.
Presence of dentures and normal care routine.
Current or past dental problems.
Other risk factors, for example diabetes, steroid treatment, smoking, alcohol intake, altered