Mouth care is an integral part of nursing practice and inpatient care. Maintaining oral health is essential to prevent infections and to maintain nutrition and communication. Many factors such as cancer treatments, dehydration, diabetes, renal failure, stroke, antibiotic therapy, phenytoin therapy, anti-depressant drugs, opioid analgesics, dementia and oxygen therapy can potentially contribute to oral disease. Therefore, many in-patients will require physical help or at least guidance about oral care from nursing staff.

Good oral and denture hygiene reduces the potential risk of horizontal transmission of infection and re-colonisation of patients following MRSA eradication therapy.

The purpose of this guidance is to:

• raise staff awareness of the importance of oral health in relation to general health
• provide guidance to staff on the oral assessment of inpatients and identify individual care needs
• provide nursing staff with clear guidance on the provision of basic oral care to inpatients.

In order to plan appropriate oral care a thorough assessment is necessary for each patient on admission or when a significant change to a patient’s condition occurs. The assessment should be made by a registered nurse with the aid of a hand held pen torch. The initial rapid assessment questions found in the Inpatient booklet (see Appendix 1) should be completed for every patient. A positive response to any of these trigger questions will highlight if the patient will require additional help from staff and an Oral Health Risk Assessment (OHRA) should be completed (see Appendix 2).

This OHRA will provide nursing staff with:

• baseline data
• the ability to monitor patient response to oral care
• the ability to identify any new problems as they arise.

The OHRA should be reviewed:

• monthly
• on a patient’s re-entry to a ward following a surgical procedure as oral needs may have altered following surgery or anaesthesia
• following a change in the patient’s condition where s/he is no longer able to able to undertake self-care.

Following completion of the OHRA staff will be able to formulate an Oral Hygiene Care Plan tailored to each individual’s needs (see Appendix 3). This should be kept under review in line with the OHRA. Daily oral care being carried out by staff should be recorded on the Oral Hygiene Daily Chart (see Appendix 4) or, in some wards, on a Care & Comfort Rounding chart

Some in-patients will have more complex oral needs e.g. those undergoing chemotherapy treatments; those with dysphagia or those with xerostomia. These patients will require more intensive oral intervention and we would direct the reader to additional documents found within the bibliography (Section 5).

For patients in the Intensive Care Unit please refer to Ayrshire and Arran’s ICU Daily Oral Care Bundle.

Patients with a diagnosed dysphagia may have difficulties managing their own secretions, managing foaming toothpaste or swallowing during mouth care. Should any swallowing difficulties be noted, please discuss with the treating speech and language therapist or make a referral to the local Speech & Language Therapy (SLT) Service.

Please see Appendix 6 for a summary of where to access the above documents.

Natural teeth or dental implants

• Teeth should be brushed at least twice daily; morning and night for two minutes.
• A pea-sized amount of fluoride toothpaste (see Appendix 5 for guidance on fluoride concentration) should be placed on a small headed toothbrush with medium strength bristles.
• Teeth and gums should be brushed in a systematic manner covering all surfaces of the teeth using a circular motion concentrating on one section at a time.
• When brushing is complete the patient should not rinse their mouth with water but should be encouraged to spit out toothpaste only. Non-foaming toothpaste is available for patients who may have difficulty spitting out excess paste or for those whom dysphagia represents an aspiration risk. For information regarding sourcing OHPFree non-foaming toothpaste, please email oralhealthimprovementteam@aapct.scot.nhs.uk.
• Dental implants should be brushed in the same manner as natural teeth.

Complete dentures

Should be cleaned morning and night with unperfumed soap or denture cleaner and water using a personal denture brush or toothbrush. This should be done over a filled basin or soft surface to reduce the risk of breakage if dropped.

• After each meal they should be rinsed in water.
• Dentures should not be worn overnight but instead soaked in liquid in a labelled denture bowl.
• Plastic dentures should be soaked in a sodium hypochlorite solution (e.g. Milton or Dentural - roughly ½ a teaspoon in a denture bowl filled with cold water) overnight or ideally for 20 minutes before being placed in plain water overnight.
• Any denture with a metal base should be soaked in chlorhexidine gluconate 0.2% (e.g. Corsodyl mouthwash) and not a sodium hypochlorite solution.
• Dentures should be rinsed in water before being re-placed in a patient’s mouth.

Please see Appendix 6 to find out how to access a Denture Information Leaflet that can be given to staff, patients or their families to give them more information on cleaning dentures and the benefits of using sodium hypochlorite.

Natural teeth and a partial denture

Please remove the partial denture from the patient’s mouth taking care not to pull on any wire clasps.

• Follow guidance for care of complete dentures.
• Follow guidance for care of natural teeth.

Edentulous

If the patient wears a complete denture this should be removed from the mouth before carrying out the below.

• Soft tissues, roof of mouth, gum ridges and tongue should be gently cleaned morning and night with a moist soft toothbrush or Moutheze brush to remove any foreign particles and plaque.
• Follow guidance for care of complete dentures.

Removable orthodontic brace

• Should be worn at all times including overnight.
• Remove the brace after each meal and rinse in water.
• Follow guidance for care of natural teeth.

Moutheze brush

Within NHS Ayrshire & Arran the MouthEze brush has replaced sponge mouth swabs which are no longer available as they pose an accepted and well documented risk to patients.

For patients in the Intensive Care Unit please refer to Ayrshire and Arran ICU Daily Oral Care Bundle 2016 for the role of MouthEze brushes.

Staff should use the MouthEze brush with dependant patients to safely cleanse inside the mouth. MouthEze can be used to:

• hydrate (moisten) the lips, tongue and soft tissues inside the mouth with water, water based gels and mouth rinses
• clean coated tongues
• remove retained food and debris from the mouth
• remove sticky tenacious secretions, crusty plugs on the palate and stringy saliva following cancer therapy treatment.

Instructions for use:

• MouthEze can be used wet or dry
• do not use if the filaments or handle appear damaged in any way
• gently sweep around the soft tissues inside the mouth
• remove food and debris - use a rotation action
• for coated tongues – moisten with water or water based gel and gently sweep across the tongue from the base to the tip
• for lubricating the mouth - dip MouthEze in water (sterile water in ICU), mouth rinse or water based gel and gently sweep around the mouth.

After use:

• unless being used to clean mucosa which is ulcerated or broken, MouthEze can be used many times with the same patient for up to 12 hours
• discard the MouthEze after 12 hours as the filaments may twist and warp and may limit the cleansing process/properties of MouthEze
• in between uses with the same patient, MouthEze can be safely disinfected.
  • rinse MouthEze thoroughly under running water
  • immerse in chlorohexidine gluconate 0.2% solution for at least 20 minutes
  • allow to air dry. A drying stand with suction pad is available.

Precaution:

• If the patient presents with ulcerated or broken tissues in the mouth, ask advice from the nurse in charge to ensure the oral mucosa is safe to be cleaned using MouthEze. If MouthEze is used, once it is removed from the patients mouth immediately discard and use another MouthEze to complete cleaning of any other areas of the mouth/oral mucosa.
• If a patient has swallowing difficulties and a bite reflex ensure that no filaments have fallen into the mouth if the patient bites down on MouthEze. In the event filaments are bitten off and are in the mouth these can either be removed with moistened gauze, a new MouthEze or a clean soft headed toothbrush.

The same principles of oral care already covered in this document apply to patients in hospital with a known or suspected case of COVID-19. However, some additional precautions are required to minimise the risk of cross-infection:

• Droplet level PPE including disposable gloves, plastic apron, eye protection and a fluid resistant surgical mask should be worn when carrying out mouth care for patients with COVID-19.
• Delivering oral care is not classed as an aerosol generating procedure but the environment where the patient is being cared for may necessitate additional airborne precautions, for example in a ward where patients are ventilated.

Mouth care for non-ventilated patients

• If the patient is having oxygen via a face mask, check with the nurse in charge before removing this for the time needed to carry out mouth care.
• These patients are more likely to cough when performing mouth care, be gentle, stand to the side or behind them, take breaks to allow the patient to rest and swallow.
• If possible, sit the patient upright.
• Do not use an electric toothbrush as this may cause droplets and splash.
• If the patient can spit, give the patient a disposable bowl to spit into.
• If the patient is unable to spit and bedside suction is available, and you are trained to use it, then use gentle oral suctioning to remove excess saliva and toothpaste.
• After brushing rinse their brush, and store with their toothpaste in a sealed named container or washbag.

Mouth care for ventilated patients

• Patients with COVID-19 will largely be ventilated because of viral pneumonia. Their mouths become very dry and will benefit from regular care to reduce the risk of getting bacterial pneumonia.
• Before commencing mouth care check with the nurse in charge that this is appropriate and for any specific care advice, especially regarding working around the endotracheal tube.
• Keep the patient’s lips and mouth moist with regular applications of products available and remove any build-up of secretions or debris using a Moutheze brush (see information in section 3.3).

All guidelines and policies require review using the NHS Ayrshire and Arran Impact Assessment Toolkit by staff trained in this process.

Staff are reminded that they may have patients who require communication in a form other than English e.g. other languages or signing. Additionally, some patients may have difficulties with written material. At all times, communication and material should be in the patients preferred format. This may also apply to patients with learning difficulties.

In some circumstances there may be religious and/or cultural issues which may impact on this guideline e.g. choice of gender of healthcare professional. Consideration should be given to these issues when treating/examining patients.

Some patients may have a physical disability that makes it difficult for them to be treated/examined as set out in the guideline requiring adaptations to be made.

Patient’s sexuality may or may not be relevant to the implementation of this guideline however, non-sexuality specific language should be used when asking patients about their sexual history. Where sexuality may be relevant, tailored advice and information may be given.

This guideline has been impact assessed using the NHS Ayrshire and Arran Equality and Diversity Impact Assessment Tool Kit. No additional equality & diversity issues were identified.

Arnold C, Brookes V, Griffiths J, Maddock S, Theophilou S (2000) Guidelines for Oral Health Care for People with a Physical Disability. British Society for Disability and Oral Health.

Caring for Smiles. Guide for Care Homes Better Oral Care for Dependant Older People. NHS Health Scotland (2020)
https://learn.nes.nhs.scot/36389/oral-health-improvement-for-priority-groups/caring-for-smiles/caring-for-smiles-guide

Recommendations on the use of fluoride toothpaste and fluoride supplements in Scotland. Scottish Consultants in Dental Public Health Group in consultation with the Scottish Dental Clinical Effectiveness Programme (2017). https://www.scottishdental.org/library/recommendations-on-the-use-of-fluoride-toothpaste-and-fluoride-supplements-in-scotland-2017/

Delivering Better Oral Health: An evidence based toolkit for prevention. Third edition. Department of Health (2017)

Fiske J, Griffiths J, Jamieson R, Manger D. (2000) Oral care for long stay patients and residents. Guidelines and recommendations. British Society for Disability and Oral Health.

Guidelines for Oral Care. Heart of Birmingham NHS Teaching Primary Care Trust, October 2008.

Mouth care advice for hospitals during the pandemic. NHS Education for Scotland (2020).
https://learn.nes.nhs.scot/29826/oral-health-improvement-for-priority-groups/covid-19-mouth-care-advice-for-hospitals-during-the-pandemic

https://learn.nes.nhs.scot/28872/oral-health-improvement-for-priority-groups/covid-19-mouth-care-advice-for-hospitals-during-the-pandemic/covid-19-mouth-care-for-the-critically-ill-patient

Mouth Care Matters: a guide for hospital healthcare professionals. NHS Health Education England (2016)

Scottish Palliative Care Guidelines (updated 2020)
https://www.palliativecareguidelines.scot.nhs.uk/guidelines/symptom-control/Mouth-Care.aspx

White paper on optimal care and maintenance of full dentures for oral and general health. Oral Care foundation (2018)

Contained within NHS A&A Inpatient Booklet. Should be completed on patient admission and reviewed:

• monthly
• on a patient’s re-entry to a ward following a surgical procedure as oral needs may have altered following surgery or anaesthesia
• following a change in the patient’s condition where s/he is no longer able to able to undertake self-care.

If the answer to any of these rapid assessment questions is “Yes”, you must now fill in a full Oral Health Risk Assessment, followed by an Oral Health Care Plan – details of how to source these documents are included in Appendix 6.
If the patient is experiencing any cognitive impairment and is unable to provide information required for Oral Health Rapid Assessment Questions or Oral Health Risk Assessment, consider consulting with next of kin.

Oral health risk assessment

Oral hygiene - care plan

Oral hygiene - daily chart

Fluoride concentration can be found on the back of most toothpaste tubes in the ingredients list and will be listed as, for example, 1000 ppmf (parts per million fluoride)

For patients at increased caries risk (considered to be the case if hospital in-patient requiring assistance in daily oral hygiene activities):

*Toothpaste with higher concentrations of fluoride (2,800ppm and 5,000ppm) should be used under the guidance of a dental surgeon.

More information on recommended fluoride concentrations can be found at Recommendations on the use of fluoride toothpaste and fluoride supplements in Scotland 2017 .