Learning outcomes
By the end of this section, you should know how to:
▪ prepare the patient for this nursing practice
▪ collect and prepare the equipment
▪ carry out mouth care according to the individual needs of the patient in both a community and an institutional setting.
Background knowledge required
Revision of the anatomy and physiology of the mouth and pharynx, with special reference to the teeth, salivary glands and oral mucosa
Revision of pharmaceutical literature related to the mouthwashes and mouth-cleaning preparations in current use
Revision of local policy related to mouth care.
Indications and rationale for mouth care
Mouth care is the use of a toothbrush and paste, a mouthwash or other mouth-cleaning preparation to help the patient to maintain the cleanliness of his teeth or dentures and to encourage the flow of saliva to maintain a healthy oropharyngeal mucosa. Good oral health is crucial to meeting fundamental human needs such as comfort, nutrition, communication and acceptable personal appearance (NHS Quality Improvement Scotland 2004).
This nursing practice is also known as oral hygiene and may be required:
▪ for any patient who has not eaten for a period of time or whose diet is restricted, as the reduction in mastication decreases the flow of saliva; this may occur during the preoperative or postoperative period, especially in patients who have undergone oral or abdominal surgery
▪ for patients who are dehydrated for any reason as the normal flow of saliva will be reduced
▪ for patients suffering from nausea or vomiting as they will be reluctant to eat
▪ for patients being treated with oxygen therapy, particularly using unhumidified oxygen, which has a drying effect on the oral mucosa
▪ for patients who are having radiotherapy or cytotoxic medication for malignant disease as this may adversely affect the cells of the oral mucosa (White 2000)
▪ for patients with any form of facial paralysis or muscle weakness as the inability to masticate adequately reduces the flow of saliva and may cause food debris to be retained in the mouth. This may include an unconscious patient or one in the terminal stages of illness
▪ for patients who have poor manual dexterity or cognitive impairment (White 2000)
▪ for patients with an oral infection such as candidiasis.
There is a lack of research on the frequency of mouth care, which will vary for each individual. The use of an effective oral assessment tool is strongly advised to ensure the early detection of problems within vulnerable patient groups (Roberts 2000). Intensive mouth care may be carried out every 2 hours, whereas mouthwashes may only be required two or three times a day but frequency should be based on individual assessment (Griffiths & Lewis 2002).
Equipment1. Suitable tray or trolley
2. Plastic gloves (non-sterile)
3. Pencil torch
4. Spatula
5. Toothbrush
6. Toothpaste
7. Container for dentures (for institutional care this should be appropriately labelled)
8. Beaker
9. Bowl or receiver
10. Towel or other protective covering
11. Mouthwash solution
12. Soft tissues for wiping the mouth
13. Receptacle for disposable items.
Additional equipment for specialised mouth care as required
Mouth-care pack or equivalent equipment
Foam sticks
Cotton buds
Prescribed medication, e.g. an antifungal agent if thrush is diagnosed
Solution for mouth cleaning
Lubrication for lips, e.g. petroleum jelly or lip balm
Suction equipment.
Toothbrush and toothpaste
The patient’s own equipment may be used if it is available; otherwise, a soft, small-headed nylon brush and toothpaste can be supplied. This is usually the most appropriate equipment for this nursing practice (Clay 2000).
Foam sticks
These are ineffective in removing debris from the teeth and gums (Clay 2000), but they are useful for rinsing or refreshing the mouth (Nicol et al 2000). Care should be taken that the foam head does not become detached and obstruct the patient’s airway.
Solutions to be used as mouthwashes
Various solutions are available, professional knowledge or individual prescription and patient preference influencing the choice of preparation used. All the solutions used should be clearly labelled and diluted according to their instructions. The procedure for checking the preparation is as for ‘Administration of medicines’ (seep. 13).
There remains little general consensus over the efficacy of oral-care agents (Milligan et al 2001).
This can be made up using common salt, one level teaspoon (approximately 4.5 g) in 500 ml of water, also being available in sterile sachets. This is an effective mouthwash for patients who have had oral surgery, especially dental extractions.
Thymol
This is prepared in solution and is the main component of most mouthwash tablets. It has a mild antiseptic effect and is well tolerated when diluted to suit the patient’s taste.
Sodium bicarbonate
This may be made up immediately prior to use. One level teaspoon of powder in 500 ml of water is a useful mouthwash for dissolving mucus and debris. A stronger solution can be used for soaking dentures before cleaning them.
Chlorhexidene
This is the most effective chemical agent for maintaining oral hygiene and for dental plaque control (Xavier 2000). Mouthwash should not take place more than once every 12 hours (British National Formulary 2005). Stronger solutions can, however, stain the teeth, and long-term use can cause mucosal damage (British National Formulary 2005).
Water
This may be the most refreshing and appropriate mouthwash to use after brushing the teeth.
Other aids for mouth care (if permitted)
Soda water
This may be appreciated as an alternative mouthwash.
Ice cubes
These may be sucked, but the number should be limited if the patient has a restricted oral intake.
Fresh fruit
This can be sucked and then removed. Pineapple, if allowed, can be very refreshing and will stimulate the flow of saliva as it contains the enzyme ananase, which can help to clean a coated tongue (Rattenbury et al 1999).
Saliva substitutes
These are useful for the treatment of a dry mouth (NHS Quality Improvement Scotland 2004).
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