Introduction

The mouth is central to many activities of daily living that we take for granted until some minor but painful problem reminds us of the importance of the condition of the mouth to our feeling of well-being. The mouth is the source of the infant’s first pleasurable activity, the sucking reflex being present at birth, and, perhaps, during teething, of the first experience of dis-ease. For individuals approaching the end of life, or for anyone who is acutely ill, good mouth care can give much comfort and relief and help to preserve dignity. Although this book addresses adult health, it is important to realise that good oral health practices laid down in childhood can influence adult health in a positive way.

Nurses remain the ‘key personnel’ in the multidisciplinary team (MDT) in the early detection of oral symptoms and potential problems patients may encounter with performing oral hygiene procedures (Murphy 2005). However, McGuire (2002) notes that: ‘…there are a number of barriers that prevent patients from receiving needed care. These barriers range from a lack of knowledge, to inconsistent practice, to administrative and environmental issues’ and oral care remains an often neglected aspect of nursing care. It has been recognised that many nurses feel uncomfortable about raising the topic of oral hygiene with their patients, and may consider an oral examination to be an ‘infringement of patients’ integrity’ (Murphy 2005). Miller & Kearney (2001, p. 241) suggest that ‘mouth care has become a ritualistic and banal activity, a topic of conflicting advice and subjective conclusions from sporadic research’. McAuliffe (2007) reports similar experiences, adding that oral hygiene practice is also carried out ‘without reference to patients’ individual needs’, and is a task delegated to junior nurses or auxiliary staff, who may have received little educational preparation. Mouth care should not be regarded as a standard procedure, but must be adapted to meet the needs of individuals in various care settings throughout life, and at various points on the health–illness continuum.

Oral diseases are generally not given priority over other complex medical problems despite the often profound effects of oral problems on a person’s quality of life (Doyle & Dalton 2008). The mouth is often the first indicator of generalised systemic disease or disease in adjacent structures and its immediate visibility gives any dysfunction a particular significance for the individual, who may be acutely aware of any disfigurement (cosmetic or functional). This can give rise to many difficulties affecting the person’s self-perception and quality of life.

Anatomy and physiology

The oral cavity has evolved as a ‘workshop’, where much activity associated with chewing (mastication), drinking and speaking takes place (Figure 15.1):

Figure 15.1 The importance of oral competence to the process of feeding, chewing and swallowing.

The mouth is situated close to many other structures (the eye, ear, nose, maxillary sinuses, pharynx, larynx and neck) and disease or injury of the mouth may also affect these areas. A thorough knowledge of the anatomy is important to understand the relationship between the blood supply and lymphatic drainage. This will affect the way certain infections and diseases will present and is important in the management of patients with these conditions.

The stages of swallowing

Swallowing (deglutition) is a complex mechanism using both skeletal muscle (tongue) and smooth muscles of the pharynx and oesophagus. Only in the mouth is there any voluntary control over the process of swallowing. The first stage (oral or buccal) must be accomplished so that the swallowing reflex is triggered when the bolus reaches the posterior pharyngeal wall, and the second stage (pharyngeal) then commences. During this stage and the third (oesophageal stage), swallowing is involuntary and is coordinated by the autonomic nervous system. Any problem in the oral phase can affect the patient’s ability to swallow normally. Several cranial nerves are involved in the acts of swallowing and voice production.

See website Table 15.1

A means of communication

The oral structures, together with throat and facial muscles, manipulate sound to give quality and resonance to speech. Thus any disturbance to the norm can cause diminution or failure of these very basic functions and so reduce quality of life. The psychosocial impact of poor oral health may be far reaching, as the mouth plays an integral role in communication through both speech and physical expression.

Saliva

This is formed by a combination of secretions from the parotid, submandibular and sublingual glands and from the numerous minor glands in the mucous membrane. Saliva plays an essential role in lubrication and protection of the oral mucous membranes (Xavier 2000), and salivary amylase is the enzyme that begins starch digestion whilst the food is still in the mouth. For more information about the physiology of salivation, see Holmes (1998).

Teeth

Teeth are important structures for biting and chewing food. Children have 20 temporary (deciduous) teeth, which are gradually replaced by 32 permanent teeth between the ages of 6 and 16 years. The dental age can be estimated in children depending on which teeth have erupted but there can be considerable individual variation. Overcrowding of teeth may necessitate extractions and orthodontic treatment in children. Impacted third molars (wisdom teeth) are removed if they cause problems themselves or with adjacent teeth.

Bones of the face (Figure 15.2)

Many of these bones are complex and fragile, and hence trauma to the mouth may result in a complicated injury.

Figure 15.2 The bones of the face.

Disorders of the mouth

Disorders of the mouth can be broadly classified into five categories:

Oral health and orodental disease

Dental and periodontal disease (Figure 15.3) continue to pose an important public health problem (Jones et al 2005), affecting about 95% of the population of the UK in varying degrees and accounting for the largest proportion of mouth disorders. Although loss of teeth is not a lethal disease, the burden of oral disease in terms of financial, social and personal impacts is considerable (Kwan et al 2005).

Figure 15.3 Periodontal disease with loss of teeth.

Changing patterns of dental health

From the early 1970s, there was a substantial improvement in dental health in the UK. More people retained their natural teeth into later life, and there was a marked decrease in dental caries in children. Dental caries, also known as tooth decay, is a disease where bacterial processes dissolve the tooth structure, causing the progressive breakdown of the hard structures of the tooth, and producing holes (cavities) in the teeth. By 1998, dentate adults had fewer missing teeth and greater numbers of sound, untreated teeth on average than in 1978. However, improvement in children’s dental health appears to be reversing and there was no improvement in 2001/2002 compared to the two previous years. Furthermore, the 2003 Children’s Dental Health Survey reported that since the previous survey in 1993, the proportion of children with plaque and gum disease had risen in 5, 8, 12 and 15 year olds (White & Lader 2004). In the UK, 40% of children have dental decay (Morgan et al 2008), but there is wide regional variation. Most epidemiological studies conclude a direct correlation between socioeconomic status and periodontal disease (Peterson & Ogawa 2005). The most recent survey into children’s dental health in the UK (Lader et al 2005) confirmed this relationship, with the average number of teeth showing obvious decay being lower among children from professional and managerial backgrounds compared with those from routine and manual families. There are serious implications for health in later years if dental disease remains untreated in childhood.

Promoting oral health

As illustrated by Box 15.1, nurses in all spheres of practice can help with early education in the simple preventative measures that are key to oral health.

Box 15.1 Information

Contribution of nurses and midwives to orodental health

Health visitors and public health nurses

Encourage oral hygiene in childhood and visits to dentist and orthodontist. This is a primary preventive function of the health visitor, school nurse and public health nurse. Educate on oral cancer prevention (smoking, alcohol and other substance abuse). Demonstrate dental hygiene. Alert parents to the need for children’s visits to the dentist. Encourage healthy eating principles.

Occupational health nurses and practice nurses

Educate on adverse effects of smoking and excessive alcohol. Raise awareness of symptoms of intraoral cancer. Advise on good handwashing practices and healthy eating.

District nurses

Identify potential problems in older people. Advise on continued dental examination. Raise awareness of oral cancer.

Nurses caring for older people

As above. Increase mouth comfort and self-esteem.

Nurses working with those with learning disability

Supervise early and continued dental care and thus minimise need for restorative dentistry.

Midwives

Give dental care advice in pregnancy.

All nurses

Encourage and/or assist with oral hygiene for patients’ comfort and health. Have dental/oral health literature available.

A nurse-led initiative described by Black (2000) is aimed at educating children and their parents to improve their diet and dental health, and to identify orodental problems early. Such health promotion messages can be reinforced throughout the most influential stages of children’s lives, enabling them to develop lifelong sustainable attitudes and skills (Kwan et al 2005).

Oral hygiene

Parents should introduce a dental hygiene routine as soon as their child’s first teeth appear, using a soft, baby toothbrush. Most children will require supervision until they are 7 or 8 years old.

The teeth

should be brushed last thing at night and, ideally, after every meal. The toothbrush should be held at an angle of 45 degrees and the teeth brushed horizontally to avoid damage to the gums. All exposed surfaces of the teeth should be brushed.

Toothbrushes

should be renewed every 3 months, and certainly when the bristles start to bend outwards. Hard brushes and traumatic technique should be avoided as these can cause abrasion of the teeth and gums.

Toothpaste

with added fluoride is recommended, except in areas with fluoridated water, as the adverse effects of fluoride (see below) depend on total fluoride dosage from all sources. Current advice is that it is unnecessary to rinse, thus leaving a film of fluoride toothpaste. It should be emphasised that ‘topical’ fluorides such as toothpaste can have a ‘systemic’ effect when they are inadvertently ingested by young children. Studies have shown that 47–72% of dental fluorosis in children can be attributed to the systemic effect of fluoride toothpaste (Jones et al 2005). Ingestion of fluoride before 3–4 years (i.e. pre-eruptive fluoride exposure) is critical to the probability of fluorosis, as this is when the formation of the permanent teeth occurs.

Fluoride

is a substance naturally present in water in some areas. It is taken up by growing teeth and makes enamel harder and more resistant to the development of caries. There is strong evidence that the incidence of caries is considerably reduced in areas of naturally occurring fluoridated water (Stephen et al 2002). However, much controversy surrounds water fluoridation (Cross & Carton 2003). Excessive intake of fluoride, either through fluoride in the water supply, naturally occurring or added to it, or through other sources, causes fluorosis. This can appear as faint white ‘mottling’; but in its severe form it is characterised by black and brown stains and pitting of the teeth. This pitting and loss of enamel in the more severe form of fluorosis increases the risk of dental caries (Levy 2003).

Dental floss

with or without added fluoride should be used to remove food and dental plaque from between the teeth and at the gumline, where periodontal disease and gingivitis often begins. Overzealous use can damage the gums and it is best not used by children.

Disclosing tablets

can be useful to demonstrate how plaque is left after inadequate brushing. Chewed after cleansing, the tablet produces a stain on any teeth still covered with plaque. Correct brushing should then remove the plaque.

Common misconceptions

Chewing gum after meals to increase saliva is of limited value in reducing decay. To be of any benefit, sugar-free gum must be chewed for 20 min and be backed up by other forms of dental care. Chewing an apple after a meal does not clean the teeth. Rather, it is acidic and can cause erosion of the enamel.

Diet

There is a direct correlation between the incidence of dental caries and availability of sucrose, with poor diet predisposing to dental decay in children. Children are particularly vulnerable to sophisticated TV advertising promoting high fat, sugar and salt containing foods, such as confectionery (Morgan et al 2008). Nurses can contribute to health education in this area, and emphasise the damaging effects of non-milk sugars, which include fruit juices, honey and sugar, especially when consumed by young children last thing at night.

Access to dental care

The dental surgery is often the first remembered clinical setting for health care. If these first visits are pleasant, a positive attitude may be created towards future regular dental check-ups, and subsequent disease can then be diagnosed early. In the adult population with learning difficulties, changes from institutional living to community-based housing may be associated with reduction in dental attendance and treatment (Stanfield et al 2003). Older housebound people face similar problems.

The future dental health of the nation may be affected by factors including regional variation in accessibility of NHS dentistry, increased treatment charges and changes in funding of dental services. Although 75% of British adults consider oral health to be important to quality of life (McGrath & Bedi 2002), only 59% of adults were likely to attend for regular dental check-ups, and younger adults (16–24 years) were less likely to do so than when they were 5 years younger (Nuttall et al 2001).

Dental and periodontal disease

Pathophysiology

Plaque

is a firmly adherent, non-calcified deposit of bacteria, mucus, food particles and cellular debris which accumulates on the surface of a tooth, particularly at the base. The microorganisms present in dental plaque are all naturally present in the oral cavity, and are normally harmless. However, in the absence of good oral hygiene plaque builds up into a thick layer and reacts with sugar to form an acid which can attack and erode tooth enamel. Saliva is also unable to penetrate the build-up of plaque and thus cannot act to neutralise the acid produced by the bacteria and remineralise the tooth surface.

Calculus (tartar)

is hard mineralised plaque which requires removal by a dental surgeon or dental hygienist.

Caries

is progressive, localised decay of teeth caused by bacterial action. It is characterised by demineralisation of the inorganic portion and destruction of the organic substance of the tooth.

Gingivitis – inflammation of the gums

Normal gums are pink (in Caucasians) or brown (in Asian and African people) and are firm with no bleeding when touched by a toothbrush. In gingivitis, the gums are inflamed and can be red to purple and often look swollen and puffy. They may be tender and may bleed easily on tooth brushing. The early stages are reversible with effective oral hygiene and dental care. Untreated, gingivitis can lead to gum recession and the formation of pockets (periodontal disease) (found in 75% of dentate adults) around the base of teeth, in which plaque and calculus can collect. Further infection from bacteria in plaque may lead to periodontitis.

Periodontitis

is characterised by gradual loss of the supporting periodontal membrane of the teeth and erosion of supporting alveolar bone (Figure 15.4). Once the periodontal membrane and bone have been destroyed they cannot be replaced and subsequent loosening of teeth occurs.

Figure 15.4 Periodontitis.

Acute ulcerative gingivitis

is caused by a mixed infection of a bacillus and spirochaetes. This is associated with poor oral hygiene and smoking, but can be associated with HIV infection and immunosuppression due to other causes. The gums are sore and bleed very easily and ulcers develop on the inderdental papillae (the cone-shaped pad of gingiva filling the space between the teeth) which may spread more deeply. There is foul-smelling halitosis, and cervical or neck lymph glands may be enlarged.

Halitosis,

commonly known as bad breath, is very common, and in most cases originates in the mouth itself (although there are other possible sources such as the airways, oesophagus and stomach). It usually results from the anaerobic breakdown of proteins by bacteria somewhere in the mouth, with the most common part of the mouth for halitosis to originate being the back of the tongue. Here, large quantities of bacteria can remain relatively undisturbed by normal activity, and the continually-forming coating of food debris, dead cells and post-nasal drip allows these bacteria to flourish.

Common presenting symptoms

The patient commonly presents to the general practitioner (GP) or dentist with a combination of symptoms which may include toothache, bleeding gums and emission of pus from the gums (pyorrhoea). If oral hygiene has been habitually poor, the patient is more likely to wait until pain is severe before visiting the GP.

Medical management

Investigations

include dental X-rays and relevant blood tests and a thorough clinical examination.

Dental surgery or outpatient procedures

Most orodental problems are treated in dental surgeries. Standard dental treatments such as extractions, fillings, etc., are carried out with the patient under a local anaesthetic administered by the dentist. More complex procedures necessitate general anaesthesia, which is administered by an anaesthetist. This is not performed in a dental surgery setting and the patient is usually referred to a specialist department in hospital. Treatment of gingivitis is called scaling (removal of the plaque and calculus), and is more easily carried out when any swelling has subsided. Mouthwashes and systemic oral antibiotics are also helpful.

Inpatient or day-case procedures

Procedures that can be classed as minor oral surgery but which may require hospital treatment in a dental hospital or oral and maxillofacial unit include:

• removal of impacted teeth, including wisdom teeth

• removal of cysts of the jaws

• minor soft tissue surgery (e.g. excision of oral polyps, frenulectomy, excision of mucoceles)

• apicectomy – excision of apex of tooth root following root canal therapy (often associated with cyst removal as well)

• pre-prosthetic surgery

• placement of dental implants.

Patients taking certain types of medication and those with the following medical conditions may require hospital treatment (Wray et al 2003):

• Diabetes mellitus – insulin dosage needs to be monitored according to blood sugar levels. There is a risk of infection in these patients (see Ch. 5).

• Heart valve disease – NICE guidelines (2000) state that the vast majority of these patients do not require any special treatment. They used to be given prophylactic antibiotics to prevent the development of infective endocarditis (see Ch. 2).

• Corticosteroid medication – must be monitored. Healing may be delayed.

• Anticoagulants – must be monitored and if necessary stopped pre-operatively or changed. There is increased risk of haemorrhage.

Nursing management and health promotion: orodental disease

Nursing considerations

Outpatient care

Individuals treated in dental surgeries or as hospital outpatients will require reassurance and advice on aftercare at home (Box 15.2).

Box 15.2 Information

Information for patients having minor oral surgery

Following surgery to your mouth, you can expect some swelling and discomfort. This may last for some days. The following information will help you in the postoperative period.

On the day of treatment

1 Rest for a few hours. For the first night following surgery, when you lie down, elevate your head with pillows if possible to prevent any bleeding.

2 Avoid strenuous exercise for 24 h, and do not bend or do any heavy lifting for 2–3 days.

3 Avoid rinsing your mouth for 24 h, even if it tastes unpleasant. It is important to allow the socket to heal, and disturbing the clot by rinsing may cause bleeding and can allow infection into the socket and delay healing. Similarly, try to avoid disturbing the clot with tongue movements, eating on that side or brushing near the extraction site for 3–4 days. You can carefully wipe the area with a clean, wet gauze pad. Chlorhexidine mouthwash is also a useful adjunct.

4 Avoid sucking (e.g. through a straw), spitting and blowing your nose, as increased positive or negative pressure could dislodge the blood clot.

5 Your lips and/or tongue may be numb. Be careful not to bite or burn them inadvertently.

6 Avoid hot food and fluids until the anaesthetic wears off. This is important as you cannot feel pain properly and may burn or scald your mouth.

7 Avoid alcohol for at least 24 h, as this can encourage bleeding and delay the healing process.

8 Try to avoid smoking for as long as possible, but at the very least for the rest of the day.

9 Stick to a liquid or soft food diet for a day or two.

10 Pain or soreness can be relieved with a mild painkiller, e.g. co-codamol or paracetamol (no more than eight tablets in 24 h for an adult). Avoid aspirin-containing medications, as this can thin the blood slightly and may lead to bleeding. Check with your chemist or dentist if you are concerned or feel that you need something stronger.

11 There may be some slight bleeding for the first day or two. If you do notice bleeding, do not rinse out, but apply firm pressure to the socket. Bite firmly on a folded piece of gauze or clean cotton material such as a handkerchief for at least 15 minutes. Make sure that the pad is placed directly over the extraction site, and replace the pad as necessary. If the bleeding has not stopped after an hour or two, contact your dentist.

12 If you are at all worried, or if anything untoward occurs, such as prolonged bleeding, excessive pain or swelling, please telephone the oral surgery department where you received treatment.

After the first 24 hours

It is important to keep your mouth and the extraction site as clean as possible, ensuring that the socket is kept clear of all food and debris. A mouthwash can now be used to cleanse the mouth. It is not necessary to purchase a proprietary mouthwash, although you can if you wish. It is the mechanical action of washing out the mouth which is of importance, rather than the substance used.

Warm salty water is very effective to cleanse and freshen the mouth. Dissolve one teaspoon of salt in a tumbler of warm water. Hold a mouthful of the solution in the mouth for a minute or two and then spit it out (but not forcefully). Finish the tumbler in the same way. Repeat the procedure several times a day for at least 5 days.

Pain that lasts up to a week or so but gradually gets better is normal. Pain that starts to get worse after 2 days is considered abnormal, and you may want to see your dentist. This may be a sign of a ‘dry socket’. This occurs when the blood clot for healing becomes dislodged or does not form. In that case, the bone and fine nerve endings are not protected and are exposed to air, food and liquids. This delays the healing process and can be painful. If you suspect dry socket, see your dentist. He/she will place a medicated dressing into the socket, which will almost instantly relieve pain. A course of antibiotics may also be prescribed if the area is infected.

Follow-up

You will have been given another appointment if further treatment is necessary. If you have any problems please contact the oral surgery department for advice.

Sources

What to do following an extraction. British Dental Health Foundation. www.dentalhealth.org.uk

Accessed 13th September 2009.

Healing after extractions and oral surgery. www.dentalfearcentral.org/healing.html Accessed 13th September 2009.

Inpatient care

Many patients are treated as day cases. However, stay may be longer if the patient has any relevant medical conditions (see above). Because of ‘dentist phobia’, patients undergoing dental surgery often experience anxiety which may seem disproportionate to the size of the procedure, and need much reassurance. Postoperatively, the patient may experience pain, swelling and bruising. The nursing care plan on the website provides an example of the care that is required following a wisdom tooth extraction.

See website Nursing care plan 15.1

On discharge, the patient should be given clear, adequate information on self-care and a number to call should further advice be needed (see Box 15.2).

Promoting oral health and comfort in special client groups

Most people are able to maintain good oral hygiene independently throughout much of their lives. Others, for reasons of physical or cognitive disability, or infirmity due to illness or advanced age, will need supervision and assistance in carrying out dental and periodontal care routines. The importance of this aspect of daily care must not be minimised, as poor orodental health can seriously compromise the individual’s well-being, both functionally and socially.

Physically disadvantaged and those with learning difficulties

Individuals with limited motor control or manual dexterity may require help with brushing teeth. Toothbrushes with adapted handles are available to aid gripping and the nurse should be aware of how these can be obtained (often from an occupational therapist). Electric toothbrushes often make tooth brushing more effective and easier to perform. Many people with limited movement depend on the mouth and teeth to hold or control equipment; it is thus especially important that their teeth are kept in good condition. Occasionally, it is difficult to gain the cooperation of a disadvantaged person who needs dental treatment; in such cases, general anaesthesia may be required even for a simple procedure. In the case of patients who have suffered a stroke, mouth care is particularly important. As recognised by Brady et al (2007), a stroke may result in physical weakness, lack of coordination and cognitive problems, all which may impact on the ability to maintain effective oral hygiene.

The older person

Effective dental care for older people can greatly enhance quality of life with regard to comfort, self-image and social interaction. Much of the care is not supported by research, and oral care practices have remained unchanged for many years.

See website Table 15.2

More people now retain their natural teeth into later life, and dentures are no longer an inevitable consequence of old age (Holman et al 2005). Good oral hygiene and regular assessment of oral/dental health for older people in hospital should form part of any nursing care plan (Box 15.3). However, Samaranayake et al (1995) found considerable unmet dental need among a group of 147 older people in five long-stay wards. Oral diseases are usually progressive and cumulative, and older people in general have a high prevalence of co-morbidities, health care challenges, and barriers to care, such as:

• Gum retraction/resorption – this occurs naturally (becoming ‘long in the tooth’), causing root surfaces to be exposed, and with abrasive wear of the teeth can necessitate restorative treatment. The tooth root is exposed, and the tooth may be sensitive due to the exposed dentin.

• Dry mouth (xerostomia) – increases the risk of tooth decay. Older people are more likely to take medications that cause xerostomia (Holman et al 2005), and may have a host of medical disorders that cause salivary dysfunction (Russell & Ship 2008, p. 237). It is difficult to estimate the prevalence of xerostomia due to the limited number of epidemiological studies available; however, it is estimated that approximately 30% of the elderly population experience this (Turner & Ship 2007). Xerostomia may predispose the patient to microbial infections, altered taste, diminished food enjoyment and impaired denture use (as retention of dentures may be difficult if the salivary film is inadequate) (Russell & Ship 2008, p. 237). Many may also complain of a coated tongue.

• Ill-fitting dentures – as a result of the natural resorption of the alveolar bone the mouth continues to change when teeth are lost. After a few years dentures will not fit effectively and should be renewed every 5–7 years. Continuous wearing of dentures can lead to the development of Candida-associated denture stomatitis (inflammation of the mouth). Dentures should therefore be removed at night, cleaned and kept in water or a weak solution of Milton or other proprietary cleanser. Dentures left dry for any length of time can shrink.

• Angular cheilitis – this often develops because of old dentures and loss of lower facial height. It is characterised by irritation and fissuring (inflammation, deep ulceration and breaks in the tissue) in the corners of the mouth.

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