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Specific patient preparations

Patients with dentures

Patients with dentures should be encouraged or assisted to remove and clean the denture at least daily. The denture should be cleaned over a towel or a water-filled sink to reduce the risk of damage if it is dropped. It should be brushed with a large toothbrush, denture brush or personal nailbrush and soap and water or denture cleaner. It should be rinsed with water before being replaced in the mouth. Denture wearers are at risk of fungal infections developing under the denture and spreading to the hard palate and should be advised to remove and soak the denture ideally overnight or at least for 1 hour. The denture should be soaked in a solution of dilute sodium hypochlorite (1 part Milton® to 80 parts water). If the denture has metal parts or if infection is present, chlorhexidine 0.2% can be used to disinfect the denture (Sweeney 2005). The denture should be rinsed well before reinsertion. It should be marked with the wearer’s name and the storage container should also be marked and should be either disposable or able to be sterilized (Chalmers and Pearson 2005). Denture wearers should also clean any remaining teeth and the gums and tongue with a soft toothbrush and fluoride toothpaste. They should also have regular dental check-ups as ill-fitting dentures can cause ulcers or irritation (Clay 2000, Duffin 2008).

Patients needing assistance

A variety of patient groups may need assistance. Patients with mental illness or learning disabilities may need encouragement or assistance to maintain their oral hygiene (Doyle and Dalton 2008, Griffiths et al. 2000). Patients with conditions affecting mobility, sight or dexterity may find it difficult to carry out oral hygiene without assistance. Practical aids such as using a mirror and sitting down rather than standing can aid independence. Use of a foam handle aid to make the toothbrush easier to hold or a pump action toothpaste can also help (Holman et al. 2005). Privacy is essential to maintain the patient’s dignity. Older patients may be at risk of oral problems due to a natural decline in salivary gland function, wear and tear of teeth, and taking medication with side-effects which can cause oral problems such as dry mouth, taste changes or increased risk of infection (Chalmers and Pearson 2005, Clay 2000, Fitzpatrick 2000). Regular assessment and assistance with maintaining oral hygiene are recommended (NHSQIS 2004). For the patient who needs assistance, it is recommended that the carer stands behind or to the side of the patient and supports the lower jaw (Sweeney 2005).

Unconscious patients

Unconscious patients require particular interventions to maintain oral hygiene and comfort. For patients who are close to death, there is a lack of evidence relating to oral care and the focus should be on patient comfort. Any interventions causing distress should be stopped; mouthcare can be offered 1–2 hourly but should be decided based on the individual’s needs (Sweeney 2005). Gentle cleaning with a soft toothbrush or foam stick is recommended and a lubricant should be applied to the lips (Dahlin 2004). In critically ill patients who are unconscious and requiring mechanical ventilation, management is different (Box 9.10).

Box 9.10 Recommendations for oral care in critically ill patients

Daily assessment.

Oral care 2–4 hourly.

Brushing with a small-headed soft toothbrush and fluoride toothpaste.

Cleaning the mouth with foam sticks and chlorhexidine mouthwash or gel for patients for whom a toothbrush would be unsuitable, for example bleeding, severe ulcers.

Use of suction to prevent aspiration.

(Abidia 2007, Stiefel et al. 2000)

It is well known that aspiration of oropharyngeal flora can cause bacterial pneumonia (Li et al. 2000). Ventilator-associated pneumonia (VAP) is a serious complication which can occur in up to a quarter of ventilated patients and has a mortality of up to 50% (Berry et al. 2007). In