A nurse is providing oral care for a client who is immobile

Oral hygiene is crucial for patients’ health, and a fundamental nursing responsibility

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Introduction

Wherever possible, patients should be encouraged and supported to carry out their own oral care. However, when they are unable to do this maintaining patients’ oral hygiene is an essential nursing duty and is considered a fundamental aspect of care (Department of Health, 2010). Cleaning patients’ oral cavity is a skill that requires practice. 

Why might patients have poor oral hygiene?

There are many reasons why patients’ oral hygiene may be poor, including:

• Inability to carry out oral care, for example due to stroke, arthritis, arm injury, head injury, surgery;
• Lack knowledge or motivation;
• Lack of access to dental services;
• Lack of money to afford equipment for oral care;
• Poor diet or reduced fluid intake;(not drinking enough);
• If the patient is nil by mouth due to surgery or has swallowing problems.

Some medications such as anticholinergic drugs and oxygen therapy can cause a dry mouth or an unpleasant taste in the mouth (Major, 2005).

Why do patients benefit from a clean mouth?

Providing effective mouthcare to patients has a range of benefits. For example, it can:

• Promote self-esteem and comfort;
• Improve appetite and enjoyment of food and drink, as poor oral hygiene can affect taste;
• Improve social acceptability and social interaction by preventing halitosis.

These benefits will all help patients to recover from illness.

What should nurses do?

Where necessary nurses should facilitate/prompt patients who are able to carry out oral hygiene for themselves, at appropriate times, such as first thing in the morning and last thing at night, as well as after meals or after vomiting.  It is important to provide the equipment to do this. For example, patients who are unable to go to the bathroom should be given water and a bowl. They should also be given privacy to carry out the procedure.

Nurses should undertake oral care for patients who cannot maintain a clean mouth for themselves.

How often should oral care be carried out?

As often as necessary. This will have been identified from the oral assessment tool and could be daily, twice daily, four-hourly, two-hourly or hourly, depending on the patient’s individual circumstances (Dougherty and Lister, 2008)

Oral assessment tools are designed to help nurses carry out a thorough assessment of the oral cavity and develop a care plan tailored to patients’ individual need. There are a variety of tools, use the one selected by your trust.

Procedure for oral assessment

• Gain consent.
• Wash hands.
• Wear gloves and apron.
• Maintain privacy as required. Assess the oral cavity using an appropriate assessment tool. You may need a tongue depressor and a torch to carry out the assessment efficiently.

Why should an oral assessment be carried out?

• To provide a baseline, initial information about the condition of your patient’s oral cavity.
• To monitor progress of oral care/treatments.
• To identify any new problems (Dougherty and Lister, 2008).

What problems might you find?

Poor oral hygiene can lead to a range of problems including dry, sore lips; ulcers; plaque; dryness; dental caries; tumours; cracks; bleeding, white/yellow deposits of candidiasis (thrush). (Renton, 2007)

The patient should be referred to a dental hygienist if specialist advice is needed, but in the meantime it is important to proceed with oral care.

Reasons to refer to a dental hygienist include excessive plaque, ill-fitting dentures, multiple ulcers. While nurses should educate patients about their oral care needs, in some cases patients would benefit from the special advice that the dental hygienist can provide.

The procedure for oral hygiene

• Gain consent (NMC, 2008);
• Assemble equipment – soft toothbrush, toothpaste, clothing protection, receiver, glass of water for rinsing mouth, tissues;
• Ask the patient to get into an upright position if possible or assist them to do this. (If the patient needs to lie flat special care must be taken to avoid choking. The procedure should be undertaken with the patient’s head turned to the side, and suction equipment should be to hand);
• Wet the toothbrush head and apply a small amount of toothpaste only. Use a gentle, rotational movement to clean the inner, outer and biting surfaces of the teeth. You may also gently brush the surface of the tongue and the gums;
• If the patient cannot tolerate the use of a toothbrush (for example due to mouth tenderness) foam sticks and mouthwash can be used instead (Dougherty and Lister, 2008);
• Allow the patient to take mouthfuls of water, rinse the mouth and spit into the receiver. Use tissues to dry around the mouth;
• Apply moisturiser to the patient’s lips if required. Artificial saliva can be used to alleviate a dry mouth (Dougherty and Lister, 2008).

Denture care

• Gain consent (NMC, 2008);
• Assemble equipment – gloves and apron, a denture brush or toothbrush, and denture cleaner or toothpaste denture products are preferable if available as they preserve the condition of the dentures compared with toothpaste (Major, 2005);
• Assess the oral cavity as above;
• Remove dentures and partial dentures from the oral cavity;
• Clean at a sink;
• Pat dry and rinse with cold water before repositioning in patient’s mouth (Hickson, 2008).

Dentures may be soaked occasionally – use specific soaking solution and follow manufacturer’s instructions. Always use a dedicated denture container, carefully labelled with the patient’s details.

Key points

• Good oral hygiene has health and social benefits, and will help patients recover from illness
• Nurses should carry out oral care for patients who cannot do it for themselves
• Before oral care is started, the patient’s mouth should be assessed
• Ensure patient privacy during oral assessment and care
• Patients may need referral to a dental hygienist for specialist advice

Department of Health (2010) Essence of Care 2010: Benchmarks for Fundamental Aspects of Care. London: DH.

Dougherty L, Lister S (2008) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Oxford: Wiley Blackwell.

Hickson E (2008) Personal hygiene. In: Richardson R (ed) Clinical Skills for Student Nurses. Exeter: Reflect Press.

Major C (2005) Meeting hygiene needs In: (2nd Ed) Baillie L (ed) Developing Practical Nursing Skills. London: Hodder Arnold.

Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. London: NMC.

Nursing and Midwifery Council (2005) Guidelines for records and recordkeeping.London: NMC.

Renton S (2007) Mouth Care In: Jamieson EM et al (eds) Clinical Nursing Practices.  Edinburgh: Churchill Livingstone.

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