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the bristles at a 45° angle. The tips of the outer bristles should rest against and penetrate under the gingival sulcus. Then move the bristles back and forth using horizontal or circular strokes and a vibrating motion (bass sulcular technique), from the sulcus to the crowns of the teeth. Repeat until all teeth surfaces have been cleaned. Clean the biting surfaces by moving the toothbrush back and forth over them in short strokes and brush tongue to remove any debris. Brushing loosens and removes debris trapped on and between the teeth and gums (DH 2005, C). This reduces the growth medium for pathogenic organisms and minimizes the risk of plaque formation and dental caries (Beck 2004, E; Clay 2000, E; Pearson and Hutton 2002, R1b). Foam sticks are ineffective for this (Beck 2004, E).

9 Give a beaker of water to the patient. Encourage patient to rinse the mouth vigorously then void contents into a receiver. Paper tissues should be to hand to dry any spillage of water. Rinsing removes loosened debris and toothpaste and makes the mouth taste fresher (Beck 2004, E).

10 If the patient is unable to rinse and void, use a rinsed toothbrush to clean the teeth and moistened foam sticks to wipe the gums and oral mucosa. Foam sticks should be used with a rotating action so that most of the surface is utilized. To remove debris as effectively as possible (Beck 2004, E; Sonis et al. 2004, R5).

11 Apply several sprays of artificial saliva to the mouth if appropriate and/or suitable lubricant to dry lips. To increase the patient’s feeling of comfort and well-being and prevent further tissue damage (Davies 2000, R1b).

12 Clean the patient’s dentures on all surfaces with a denture brush or toothbrush and soap and water or denture cleaner. Check the dentures for cracks, sharp edges and missing teeth. Rinse them well and return them to the patient. Cleaning dentures removes accumulated food debris which could be broken down by salivary enzymes to products which irritate and cause inflammation of the adjacent mucosal tissue (Sweeney 2005, R5).

13 Dentures should be removed for at least 1 hour but ideally overnight and placed in a suitable cleaning solution. Dentures can easily become colonized by bacteria. Soaking can disinfect the denture, discouraging bacterial growth (Clay 2000, E; Sweeney 2005, R2b).

14 Floss teeth (unless contraindicated, for example clotting abnormality, thrombocytopenia) once in 24 hours using lightly waxed floss. To floss the upper teeth, use your thumb and index finger to stretch the floss and wrap one end of floss around the third finger of each hand. Move the floss up and down between the teeth from the tops of the crowns to the gum and along the gum lines wherever possible. To floss the lower teeth, use the index fingers to stretch the floss. Flossing helps to remove debris between teeth. Flossing when patient has abnormal clotting or low platelets may lead to bleeding and predispose the oral mucosa to infection (Clay 2000, E; Beck 2004, E).

15 Discard remaining mouthwash solutions. To prevent infection (Fraise and Bradley 2009, E).

16 Clean the toothbrush and allow it to air dry. To prevent the risk of contamination (Jones 1998, E).

Postprocedure

17 Ensure the patient is comfortable.

18 Wash hands with soap and water and dry with paper towel or use alcohol handrub. To reduce the risk of cross-infection (Fraise and Bradley 2009, E).

Problem-solving table 9.1 Prevention and resolution (Procedure guideline 9.6)

Pain

Pain is a universal human experience. It is the third most common reason why people visit their General Practitioner.

Treating the disease or condition that causes pain often resolves the problem. However, on other occasions treatment is not totally successful (e.g. diabetic neuropathy) and sometimes the cause of the pain is not entirely clear (e.g. pain following surgery, low back pain). Pain then persists.

Chronic pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Statistics show