Assisting individuals with oral hygiene in nursing
Oral hygiene may involve the use of a toothbrush and paste, a mouthwash or other mouth cleaning preparations, such as interdental sticks and floss, to achieve and maintain the cleanliness of the teeth or dentures, the gums, hard and soft palates and lips. It is considered an essential nursing procedure as an unkempt mouth can prove to be a serious health hazard over time for some individuals. Assessment and care of the oral cavity should therefore form part of a client’s daily hygiene routine, and efficacy of interventions should be continuously evaluated.
The functions of the mouth are:
• breathing
• speaking
• eating
• tasting
• drinking
• smiling
• kissing.
A healthy mouth should:
• be pink and moist, including the tongue, oral mucosa and gums
• have teeth/dentures that are clean and free of debris
• have adequate salivation
• have lips that are smooth and moist
• display no evidence of difficulties with eating or swallowing.
In order to deliver appropriate oral hygiene, it is recommended that an oral assessment tool be used to identify a client’s oral health status. The following are some of the specific points to consider when assessing an individual’s oral hygiene:
• Physical
fluid and dietary intake medication – some drugs can alter oral hygiene needs, including antibiotics, steroids, diuretics, drugs used in cytotoxic therapy, antihistamines, antispasmodics, anticholinergics, psychotropics, antidepressants, tranquillizers and opiates client receiving oxygen therapy or oral suction level of consciousness immune status physical disabilities, for example unable to move tongue from side to side, unable to empty oral cavity when eating health status; note particularly any renal impairment, diabetes or anaemia does the client have a tracheostomy? have they had a laryngectomy? ability to self-care surgery – oral, upper gastro-intestinal manual dexterity smoking age dentures/braces, full/partial, well fitting/ill fitting condition of lips, mucous membranes, gums, hard and soft palates (smooth/pink/moist/dry/cracked/ulcerated/bleeding)
• Psychological
Confusion disorientation depression level of self-esteem perceptions of self
• Sociocultural
health benefits values
dietary beliefs
• Environmental
availability of clean/running water supply other resources, for example toothbrushes, toothpaste privacy
• Politico-economic
limited finances for a healthy diet or resources
Performing oral hygiene
Performing oral hygiene can help to maintain healthy structures of the oral cavity, retain moisture, remove debris, prevent plaque and reduce the risk of infection, as well as adding to the client’s comfort and well-being. Clients should be encouraged to perform oral hygiene immediately after eating and more frequently if their health is compromised. Toothpaste, toothbrush and water are the cheapest, most reliable and most effective tools for mouth care, though a doctor, dentist or dental hygienist may sometimes recommend other products from time to time if a client’s oral hygiene is compromised (see Table 3.1). National standards for oral hygiene, and for personal hygiene, have been developed by the Department of Health. These can be accessed at www.doh.gov.uk/essenceofcare.
The equipment needed consists of spatula/torch for oral inspection; disposable gloves and apron; solutions/cleaning agents/mouthwash (all solutions should be freshly prepared in accordance with manufacturers’ instructions); toothpaste, denture cleaners; paper towels; clinical waste bag; water (drinking); denture pot if required – labelled; Vaseline/soft white paraffin gel; towel or protective clothing; tissues for wiping the mouth; suction equipment (if needed); airway (if needed); and an oral toilet pack if needed (this may already contain paper towels, disposal bag).
The frequency of this procedure should be based on regular oral cavity assessment and client preferences. In order to maintain a moist and healthy oral cavity clients should be encouraged to take frequent sips of fluids. Alternatively, soda water or ice cubes can be offered to freshen the mouth. Sucking on fresh fruit, if allowed, can also provide refreshment and helps stimulate saliva production, particularly pineapple.
Mouthwashes
A variety of mouthwash solutions are available on the market. Selection of mouthwash should be based on the following factors:
1 a thorough oral assessment
2 nurses’ knowledge base regarding the suitability of a particular solution for a client
3 clients’ preferences
4 individual prescription.
It is important that the mouthwash solution is constituted according to the manufacturer’s instructions and its use is monitored and evaluated. Some solutions, such as chlorhexidine gluconate, are classed as medications and should therefore always be prescribed and administered in accordance with local drug administration policies.
In promoting cleanliness and comfort, clients may use or be encouraged to use other mouth care aids such as dental floss. Flossing helps remove plaque and tartar between the teeth and thus reduces the potential for gum inflammation and infection. Flossing can be performed prior to or following teeth cleansing.
Care of dentures
An important aspect of oral hygiene is the care of prostheses, which include dentures, plates and braces. These are the client’s personal property and need to be handled carefully to avoid damage and breakage. Note that mouth care on unconscious clients should be undertaken with great caution and preferably in the presence of a registered practitioner. Suction equipment should always be at hand as there can be a significant risk of aspiration or choking in this client group.
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