About this course:
This module aims to provide an overview of oral care, its clinical significance, and best practices to help nurses provide optimal care, patient education, and enhance patient outcomes.
This module aims to provide an overview of oral care, its clinical significance, and best practices to help nurses provide optimal care, patient education, and enhance patient outcomes.
By the completion of this learning activity, the nurse should be able to:
- define key terms related to oral care
- explain the procedure for oral care of acutely and chronically ill patients
- discuss the approach for oral care in patients receiving mechanical ventilation
- describe oral care in patients receiving chemotherapy or radiation
- discuss oral care in patients with mucositis
- describe oral care in patients in long-term care facilities and at end-of-life
- discuss nursing implications in oral care
Dentifrice- powder or paste used to clean teeth
Dental caries- areas of decay in teeth caused by the breakdown of tooth enamel
Periodontitis- severe gum infection or gum disease which can lead to tooth and bone loss
Trismus- reduced ability to open the jaws caused by spasms of the muscles, also called lockjaw
Xerostomia- decreased or absent saliva production (Wilkins, 2017)
Primary care providers, including advanced practice registered nurses (APRNs), should perform oral health risk assessments to identify medical treatments and diseases impacting oral and overall health (Perry et al., 2018). There are over 350 species found in the standard oral flora of a healthy human. Gram-positive streptococci predominantly populate this flora. Humans are equipped with natural defenses against pathogenic microbes, such as mucus flow facilitated by cilia into the gastrointestinal tract, bypassing the respiratory tract. Nasal hair acts as a biological filter for air entering through the nose during inspiration. Fibronectin is a glycoprotein found on epithelial cell surfaces within the oral and tracheal mucus membranes that prevents bacterial attachment. Saliva prevents tooth decay by gently rinsing away debris, neutralizing acidic foods/drinks (e.g., soda, tomatoes), and remineralizing teeth surfaces. Saliva also contains immunoglobulin-A (IgA) to reduce microbial adherence in the oral cavity (Pear et al., 2007).
Research demonstrates that within 48 hours of admission to an acute care facility, the patient’s oral flora becomes more virulent with aerobic gram-negative bacilli, such as P. aeruginosa. The saliva of an acutely ill patient contains more proteases, which break down and thus reduce the amount of fibronectin. If oral hygiene is not performed within 72 hours of intubation, bacteria begin to harden and form a biofilm on teeth, leading to plaque formation and gingivitis (inflamed gums or gingiva). Intubation with an endotracheal tube (ETT) bypasses many of the body’s natural defenses. Patients who are sedated and intubated have significantly reduced salivary flow, leading to xerostomia and mucositis (inflammation of the mucous membranes; Pear et al., 2007; Quinn & Baker, 2015). Xerostomia can also be caused by several common medication classes, such as opioids, diuretics, corticosteroids, antidepressants, anticholinergics, antihistamines, and supplemental oxygen (Davis & Laybourne, 2019). The Centers for Disease Control and Prevention (CDC, 2004) guidelines regarding the prevention of hospital-acquired pneumonia (HAP) recommend the reduction of oropharyngeal colonization to prevent pneumonia in both acute patients and long-term care (LTC) residents at increased risk of developing pneumonia. Studies indicate that optimal oral care may reduce ventilator-associated pneumonia (VAP) and HAP rates by as much as 60% (Pear et al., 2007; Quinn & Baker, 2015).
Older adults and LTC residents, although not acutely ill, are at increased risk for oral diseases and infections due to:
- decreased salivary flow, leading to rapid tooth decay
- use of multiple prescriptions
- prior head or neck radiation
- artificial cardiac valves
- faulty cardiac valves
- history of endocarditis (Crow, 2017)
Oral Care Basics
Ensuring good oral health in critically and chronically ill patients is imperative to reduce the risk of healthcare-associated infections. It is essential for preventing and controlling oral conditions and other infectious diseases, consequently impacting patient outcomes. Adequate oral health can enhance patient comfort and promote nutrition. Those at highest risk for poor oral health include patients who are older, malnourished, immunosuppressed, dehydrated, and those on a mechanical ventilator. Patients who use tobacco and alcohol regularly or cannot brush their own teeth are at increased risk for poor oral health (O’Reilly, 2003; Perry et al., 2018; Wilkins, 2017). Oral care can also affect the patient’s quality of life. In LTC and older adults, losing teeth and halitosis (bad breath) can lead to isolation due to embarrassment, malnutrition, and communication difficulties (Crow, 2017).
Since compliance with oral care policies remains low, The Joint Commission and the American Dental Association developed educational materials to improve this. Time is cited as the most common barrier to implementing good oral care practices (Crow, 2017). Additional barriers include a lack of staff awareness regarding its importance, inadequate equipment, or insufficient staffing (Davis & Laybourne, 2019). Facilities should consult evidence-based practice guidelines and develop regular staff trainings to ensure that nurses and assistive personnel are educated on the clinical significance, purpose, and need for performing routine oral hygiene for all patients. Family and patient education materials should be visible to reinforce the importance of oral care and its impact on overall health. Quarterly reports to the staff on the consistent completion of oral care and how this correlates with the current rate of HAP/VAP in that unit or facility have also been shown to increase staff compliance (Quinn & Baker, 2015). According to one study, 84 to 100% of residents in LTC did not receive any oral care on any given day, and only 27% of the LTC facilities surveyed had the required oral care supplies available. Care providers were observed using the same gloves to help the residents use the toilet and then assist them in oral care (Crow, 2017).
Oral hygiene includes brushing and flossing between teeth and rinsing the oral cavity. Many factors influence the methods used for oral hygiene in hospitalized patients. It is the nurse’s responsibility to determine the ideal method and frequency of oral hygiene based on the patient’s diagnosis and clinical status using evidence-based guidelines. Oral care recommendations vary by patient population and setting. Protocols on a general medical/surgical floor may differ from those of an oncology unit, an intensive care unit (ICU), and LTC facilities (Perry et al., 2018).
Healthcare organizations should invest in developing evidence-based oral care protocols for all levels of care, not just ICU patients. While VAP and HAP result in similar mortality rates, the incidence of HAP is more significant (only 38% of HAP cases are VAP; Quinn & Baker, 2015). HAP and VAP account for 22% of all hospital-acquired infections. About half of HAP patients develop severe complications, such as respiratory failure, septic shock, empyema, renal failure, or pleural effusion (Kalil et al., 2016). When surveyed, less than 60% of hospital nursing staff indicated that they assessed their patient’s oral health or their ability to perform oral care daily (Davis & Laybourne, 2019). Training should be provided to both nursing and assistive staff to ensure adequate knowledge and understanding of the protocols. A nurse should assess all hospitalized patients at the time of admission, including
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Dental caries appear as a discolored tooth or teeth: chalky-white, brown, or black areas of discoloration (see Figure 1). Gingivitis causes redness or erythema of the gums and may indicate periodontal disease. Periodontitis presents with receding gums, inflammation, gaps between the teeth, and halitosis. The presence of cheilosis (dry, cracked lips), stomatitis (inflammation of the patient’s mouth tissues or structure), and mucositis should be documented. Tongue appearance should be noted, such as a dry, cracked, or coated tongue or the presence of a geographic tongue (Perry et al., 2018). Geographic tongue, also referred to as benign migratory glossitis, is a benign condition more often seen in patients with psoriasis and reactive arthritis. It creates a map-like appearance on the tongue (see Figure 2) with smooth red patches separated by white borders. If associated with pain (typically burning), this may be managed with an antihistamine mouthwash, topical analgesics, or nonsteroidal anti-inflammatory drugs (NSAIDs; Cleveland Clinic, 2019).
Thrush, or oropharyngeal candidiasis, is a fungal infection that affects the mouth and throat. It presents with generalized erythema of the oral mucosa with white patches along the inner buccal mucosa, the tongue, the roof of the mouth, and the throat (see Figure 3). The patient often reports a cotton-like feeling, pain while eating or swallowing, and a loss of taste. It is more common in patients with diabetes, cancer, HIV/AIDs, those who wear dentures, use tobacco, or take corticosteroids or antibiotics chronically (CDC, 2021).
The oral care procedure for most patients is straightforward. Equipment may include the following:
- a soft bristle toothbrush (or toothette sponges),
- nonabrasive fluoride toothpaste or dentifrice,
- dental floss,
- water in a glass with a straw,
- alcohol-free antiseptic mouth wash,
- an emesis basin,
- and bath towels (Perry et al., 2018)
Disposable foam swabs, lemon glycerin swabs, and gauze should not be used for oral care in adult patients. Guidelines recommend using a toothpaste with sodium bicarbonate or a similar substance to reduce the presence of mucus and biofilm. Alcohol mouthwashes should be avoided as they lead to excessive drying of the oral mucus membranes. Oral rinses that contain hydrogen peroxide or chlorhexidine gluconate (CHG) are generally recommended. The CDC HAP prevention guidelines (2004) suggest the perioperative use of 0.12% CHG oral rinse in all cardiac surgery patients but was unable to confirm the recommendation of its use in all postoperative or critically ill patients. Oral hygiene should be performed at least twice daily, up to four times daily (after meals and before bed), yet the research on oral care frequency in hospitalized patients outside of the ICU is scarce (Pear et al., 2007; Quinn & Baker, 2015). Chlorhexidine helps prevent infection by creating a film that adheres to the teeth and prevents the growth of gram-positive organisms (Shea, 2021). The CDC (2004) guidelines did not recommend the use of topical antimicrobial agents. A water-based moisturizer should be applied to all patients’ lips regularly (every 2 hours; Pear et al., 2007; Quinn & Baker, 2015).
In functionally independent hospitalized patients, oral hygiene should be facilitated and encouraged by staff but performed by the patient using approved supplies three times a day (after meals) and before bed. This process should include brushing with a soft-bristled brush for 1-2 minutes, using an oral rinse, followed by applying a lip moisturizer (Quinn & Baker, 2015). In most cases, oral hygiene in average-risk hospitalized patients who require assistance can be delegated to unlicensed assistive personnel (UAP). The UAP should be made aware of any special precautions such as aspiration precautions, for which the UAP should keep the head of the bed at least 30° or higher. The UAP should be instructed to alert the nurse of any changes in the oral mucosa; bleeding, coughing, or choking during the procedure; or complaints of pain. The nurse or UAP should wear clean gloves (Perry et al., 2018). All instances of oral care, even those performed by the patient, should be thoroughly documented in the patient’s medical record (Quinn & Baker, 2015).
In patients who are dependent for oral care or at risk of aspiration, a suction toothbrush should be used if available. The brush is moistened using the antiseptic mouth rinse (in lieu of toothpaste) and attached to continuous suction during the hygiene procedure. The use of an oral rinse after brushing is typically not recommended in these patients. Following brushing, debris should be removed using suction. Dentures should be removed and brushed using warm water whenever oral care is performed. Dentures should also be removed overnight and soaked in commercial denture cleaner (Quinn & Baker, 2015).
Special Considerations for Long-Term Care Residents
The oral health of LTC residents can affect systemic conditions and nutritional status. Common oral problems seen in LTC patients include periodontal infections, difficulty biting and chewing, weight loss due to oral problems, toothaches, fractured teeth, loose teeth, dental caries, ill-fitting dentures, and lost fillings or crowns (Wilkins, 2017). Resistance to oral care and feedings can be seen as combativeness or advancing dementia, but patients with aphasia may not be able to communicate toothaches or sensitivity. (Crow, 2017). The Oral Health Screening Tool for Nursing Personnel (OHSTNP) was designed to assist LTC facility staff in assessing residents’ oral health and identifying those needing a dentist referral (see Figure 4). The OHSTNP has been found to be a reliable and valid screening tool that can be used to screen natural teeth, dentures, and the oral cavity and its functions, with improved sensitivity and specificity when the nursing staff is instructed to refer those with alterations in natural teeth/dentures or severe alterations in any other category (Tsukada et al., 2017).
The procedures for oral hygiene in LTC residents mirror those described above for acutely hospitalized patients in most facilities. The Joint Commission mandates that an accredited nursing care center “provides supplies, equipment, and adaptive self-help devices to patients and residents to support restorative services,” but they do not mandate specific supplies. Recommended supplies that should be provided to each resident include the following:
- a toothbrush
- CHG mouthwash (applied via brush if the resident is unable to rinse)
- minimal intervention remineralizing toothpaste
- floss holders
- interproximal brushes (Crow, 2017)
For terminally ill patients, gentle cleaning of the teeth, tongue, and mucosa should be performed daily to improve comfort and enhance dignity based on the patient’s preferences. Candida oral infections affect as much as 79% of terminally ill patients. Xerostomia is also common due to medications, dehydration, and mouth breathing. Caregivers can moisten the mouth and lips using water or ice chips. Oral lesions are also common in terminally ill patients, causing discomfort while talking or eating. Significant weight loss typically causes dentures to no longer fit properly, making chewing and speaking more difficult and causing mouth lesions. The dentures may need to be relined with soft materials to prevent oral lesions in combination with proper daily hygiene and denture cleaning (Wilkins, 2017).
Special Considerations for Cancer Patients
Chemotherapy attacks rapidly dividing cells, and since it cannot differentiate between cancerous and healthy cells, oral complications are common. Radiation therapy is a localized cancer treatment that affects a cell’s ability to replicate by damaging its genetic material. When radiation is directed at the oral cavity (such as for tonsillar or salivary gland cancers), it impacts the integrity of the oral mucosa. Side effects of chemotherapy or radiation affecting the oral cavity include mucositis or stomatitis, xerostomia, salivary gland hypofunction, infections, bleeding, osteonecrosis (or osteoradionecrosis) of the jaw, radiation caries, taste loss, and trismus. Stem cell transplants may also have oral complications, including oral mucositis, oral infection, periodontal infection, xerostomia, dental caries, and difficulty eating or chewing (Wilkins, 2017).
Patients who receive optimal oral care before, during, and after cancer therapy have a lower risk of developing oral complications. Patients should undergo a complete dental evaluation with a dentist before starting and possibly during treatment. Dental extractions or removal/repairs of caries may be beneficial at least two weeks before starting chemotherapy. Patients receiving chemotherapy must consult with their oncology team before any dental or dental hygiene procedures. Blood work should be ordered 24 hours before oral surgery or invasive procedures. Dental work should also be postponed if the patient’s platelet count is less than 50,000/µL (50 x 109/L) or neutrophil count is less than 1,000/µL (1.0 x 109; Wilkins, 2017).
Oral care protocols during cancer treatment may include brushing of teeth with a soft toothbrush and fluoride toothpaste after every meal and at bedtime. The tongue may also be brushed gently with a soft toothbrush and water. Every two to three hours while awake, the patient should rinse their mouth with ¼ teaspoon of baking soda, 1/8 teaspoon of salt in 1 cup of lukewarm water. A plain water rinse should follow this. During radiation treatment, patients should be told to report trismus, pain, or weakness in their jaw. Patients should also be encouraged to exercise their jaws three times daily by opening and closing their mouth as far as possible without pain and repeating this 20 times each session (Wilkins, 2017).
Patients receiving chemotherapy with a fever of unknown origin should be assessed for evidence of bacterial, fungal, or viral oral infections. Patients should be told to avoid spicy or acidic foods, as well as tobacco and alcohol. Only sugar-free candy, gums, or sodas should be used (Wilkins, 2017).
Cryotherapy (the use of ice chips) is recommended before and during the administration of some chemotherapy agents (e.g., high-dose melphalan [Alkeran] for multiple myeloma or 5-fluorouracil [Tolak] for some head and neck cancers) to prevent oral mucositis (Wilkins, 2017). In addition, oral hygiene protocols typically include the following:
- rinsing the mouth before and after meals and at bedtime with one of the following:
- normal saline (one teaspoon of table salt in one quart of water)
- salt and soda (one-half teaspoon of salt and two tablespoons of sodium bicarbonate in one quart of warm water)
- using an ultra-soft bristle toothbrush and replacing it frequently
- using nonabrasive toothpaste, and avoiding whitening toothpaste
- utilizing a water-based lip moisturizer (oil-based can promote infection)
- avoiding irritants such as:
- commercial mouthwashes and mouthwashes with alcohol
- lemon or glycerin swabs
- spicy, hot, sharp, or acidic foods
- avoiding dental floss when the platelet count is under 40,000/µL (50 x 109/L)
- increasing daily fluid intake to 3L
- consuming a high protein diet
- removing partial or full dentures whenever possible, and especially if ill-fitting or when oral sores are severe (Henry & Goldie, 2016; Wilkins, 2017)
The World Health Organization (WHO) Oral Mucositis Scale can measure and document mucositis (see Table 1).
For patients with dental pain or oral mucositis, oral care can cause anxiety and discomfort, making the process stressful and time-consuming (Crow, 2017). Oral rinses containing diphenhydramine HCL (Benadryl) are often used in combination with a coating agent or topical anesthetic for symptom control in established mucositis. Patients with oral pain due to mucositis can swish and spit a prescribed topical anesthetic solution 30 minutes before eating. Doxepin (Silenor) mouth rinse is another option that may be an effective treatment for pain management in patients with oral mucositis. However, morphine sulfate (MS Contin) or transdermal fentanyl (Duragesic patches) may be required in patients receiving high-dose chemotherapy or radiation treatment (Wilkins, 2017).
Patients with xerostomia should sip water frequently or use ice chips, sugar-free gum, or candy. A saliva substitute spray or gel can be used. Lemon glycerin swabs should be avoided, as well as hot, spicy, salty, sharp, or sugary foods. Foods should be moistened with liquids or gravies before eating (Wilkins, 2017).
Special Considerations for Mechanically Ventilated Patients
VAP is a common, preventable, and costly complication of mechanical ventilation. Implementing prevention measures for aspiration and oral bacterial translocation to the lower respiratory tract is necessary (Ignatavicius & Workman, 2015). About 10% of patients receiving mechanical ventilation experience VAP. While all-cause mortality estimates for VAP patients range from 20-50%, the direct mortality rate for VAP was recently estimated at 13%. Recent studies also estimate that VAP is associated with a cost of approximately $40,000 per patient (Kalil et al., 2016). VAP is a threat for all patients using mechanical ventilation, with increased occurrence the longer a patient is intubated. An artificial airway will be colonized with bacteria within 48 hours, risking pneumonia development (Ignatavicius & Workman, 2015).
Infection can be prevented through strict adherence to infection control. The focus for VAP prevention was initially placed on aspiration; however, many studies showed that oral care improvement significantly contributed to VAP reduction. Oral care is a crucial component of VAP prevention, although there are variations in policies for timing, products used, and application methods. Ventilator bundles, order sets designed to prevent VAP, usually include orders to perform oral care per agency policy and using an antimicrobial rinse such as CHG, among other things. Even though oral care is vital to VAP prevention, a best practice protocol has not yet been identified. Some methods of oral care used include toothbrushing or sponge swabs. The products most commonly used include CHG rinse or sodium chloride solutions. Oral care frequencies range from twice daily to every 2 hours (Ignatavicius & Workman, 2015). Many protocols utilize a frequency of every 4 hours (Quinn & Baker, 2015).
Careful assessment of the ventilated patient’s mouth is recommended daily, noting any bleeding, odor, discharge, or ulceration. Teeth should be inspected for dental caries, trauma, and any missing or broken teeth. During oral care, the nurse should palpate along the cheeks, jaw, and gumline for swelling or enlarged lymph nodes, and placement of ETT and nasogastric tubing should be assessed. Mucosal membranes within the oral cavity should be kept moist, and the pooling of secretions should be avoided with frequent suctioning of oral and subglottic secretions (Pear et al., 2007; Shea, 2021). The lips can be swabbed with a toothette soaked in water or sterile water between prescribed cleanings to prevent drying and cracking, and water-based ointment or cream is recommended to provide moisture (Shea, 2021).
The most recent guidelines for VAP prevention were published in 2014 by the Society for Healthcare Epidemiology of America. Routine oral care with CHG in ventilated adults may decrease the rate of VAP. Still, the moderate-quality evidence was insufficient to determine if this impacts the duration of mechanical ventilation, length of stay, or mortality. Similar assessments were made by the 2014 guidelines regarding mechanical tooth brushing. Selective oral decontamination with nonabsorbable antibiotics was reviewed, but the data on the associated risks (increase in antimicrobial resistance) and benefits were deemed insufficient (Klompas et al., 2014).
As described above with other dependent hospitalized patients, a suction toothbrush should be used if available. The oral cavity should be suctioned before and after the completion of oral care. The brush is moistened using the antiseptic mouth rinse (in lieu of toothpaste) and attached to continuous suction during the hygiene procedure. Following brushing, debris and any secretions should be removed using suction (Quinn & Baker, 2015). A new toothbrush should be used for each oral care episode. Alternately, a small amount of the CHG solution can be poured into a medicine cup and a toothette soaked in the solution. The teeth, tongue, and gums can then be scrubbed gently with the toothette using small, circular motions. Any remaining CHG should be suctioned from the mouth, not rinsed. It should be noted that CHG can stain artificial teeth, and with prolonged use, it can stain natural teeth. These stains are easily removed during dental cleanings in most cases. After brushing, the mouth may be rinsed with sterile water and suctioned in some protocols, but rinsing should not occur for two hours after CHG or oral nystatin rinses. Chlorhexidine should be avoided in patients with severe mucositis or an allergy to CHG (Shea, 2021).
Dentures and partials should be removed and placed in a denture cup with a denture cleaner. Chlorhexidine should not be used on dentures (Shea, 2021). In ventilated neonates, the guidelines recommend regular oral care with sterile water. In pediatrics, routine oral care with a toothbrush or gauze is recommended over the use of CHG (Klompas et al., 2014).
Oral Care Nursing Implications
A nurse-led oral care program can reduce HAP rates by up to 60% and save millions a year (Quinn & Baker, 2015). As oral health impacts patient quality of life and systemic health, organizations such as the Oral Health Nursing Education and Practice (OHNEP) have been formed to improve primary care collaboration with dentistry and oral hygiene. Innovative methods to integrate oral health and primary care are being sought to give people access to dental care and improve health equity in the United States. Since primary care is the main point of entry for patients in the health system, it presents an opportunity to help meet patients’ oral care needs across all socio-economic groups (OHNEP, n.d.).
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