Mouth care for nurses

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mouth care for nurses

Mouth care is an area in nursing that seems to have a low priority (Griffiths and Boyle, 1993). However the status of a seriously ill patient¡¦s mouth and oral mucous can influence several other functions such as the ability to eat, swallow food, digest food and even the ability to speak. All these processes can be affected by poor mouth care (Walton and Miller, 2001). For some patients failure to identify and rectify poor oral hygiene can be life threatening, for example in chemotherapy patients, the mortality rate due to Candidemia (systemic candidiasis) is estimated to be as high as 71% to 79% (Shay, Truhlar and Renner 1997). It is therefore important that an oral status is formulated for the comfort and well being of the patient (Adams, 1996), as oral care is a very important nursing activity and is essential in providing comfort, preventing infection and maintaining the patients nutritional status (Holmes, 1996).

Mouth care is a vital aspect of patient care especially for the seriously ill patient as they are usually wholly dependant on others to provide it, oral hygiene and mouth care for this type of patient is clearly a nursing responsibility, so the intention of this essay is to explore this area of nursing practice in depth. Basic anatomy of the oral cavity and common oral problems will be examined; this area of care will also be applied to the critically ill patient to show the importance of oral hygiene to the unconscious or intubated patient. This essay will also examine what types of equipment may be used in the delivery of mouth care, what an oral assessment entails and how oral care may be implemented.

Anatomy of the Mouth

The mouth is the beginning of the digestive tract and its function can be summarised as follows:-

„«     Analysis of material before swallowing
„«     Mechanical processing due to the actions of the teeth, tongue and palatal surfaces
„«     Lubrication by mixing with mucus and salivary gland secretions
„«     Limited digestion of Carbohydrates and lipids

(Martini, 2001 p853)

The oral cavity contains the tongue, teeth and gums; the oral cavity is lined by the oral mucosa which consists of stratified squamous epithelium. Other areas of the oral cavity are covered with a layer of keratinised cells and these areas are usually subjected to severe abrasion such as the surface of the tongue, parts of the hard palate and parts of the roof of the mouth.

The tongue

The functions of the tongue can be summarised as follows:-

„«     Mechanical processing via compression, abrasion and distortion.
„«     Manipulation of foodstuffs to aid in chewing and to help prepare for swallowing.
„«     Sensory analysis of materials via touch, temperature and taste receptors.
„«     The secretion of mucus and an enzyme called Lingual lipase.

(Martini, 2001)

Teeth and Gums

The teeth aid in the mechanical breakdown of food, they are two parts to the teeth; the part embedded in the gum is referred to as the root, the exposed part of the tooth is called the crown (Turner, 1996). The gums (or gingival) are composed of squamous or parakeratinized epithelium and underlying fibrous connective tissue. The gums attach to the neck of the tooth and this attachments integrity is a major factor in gingival and periodontal disease (Evans, 2001).


Within the oral cavity there are three pairs of salivary glands that supply salvia via ducts to the oral cavity; these glands are known as the Parotid, Sublingual and Submandibular. Salvia is composed of mucus which keeps the oral cavity moist and acts as a lubricant to aid in mastication (chewing), salvia also contains Serous exudates that have bactericidal properties that help to prevent infection (Little, 1996). Salvia production and movement is essential in maintaining a healthy oral cavity (Turner, 1996).

Common oral problems

Fungal problems are common in the very young and old, patients who are on antibiotic therapy or who are immunocompromised are also at risk. The common cause of a fungal infection is Candida albicans which produces Thrush (Griffiths and Boyle, 1993). Candidiasis (Thrush) is a yeast like pathogenic fungus of which there is three main types, Perleche which appears as cuts on the lips and the corners of the mouth, Sub-acute thrush, this appears as loose flaky, cream coloured plaque and an inflamed red tongue and Chronic thrush identified by a swollen red tongue (Turner, 1996). Most fungal infections are treated with a topical medication such as Nystatin (Evans, 2001).

Streptococcal infections are the predominate bacterial infections found in the oral cavity, gram negative organisms such as E. coli, Klebsiella, Pseudomonas and Proteus are the most common. Ulcers infected with E. coli, Klebsiella and Proteus is usually raised, yellow-white and moist whereas ulcers infected with Pseudomonas are necrotic in appearance. Gram positive infections are rare and appear as a dry, round brownish wart. Bacterial infections can be treated with topical applications of bacitracin, neomycin or polymycin B (Evans, 2001).

Viral infections can appear as a cluster of vesicles or ulcerations on the lips or mucosa, these symptoms can be painful and can include gingival swelling and inflammation. The most common type of viral infections is Coxsackie viruses and Herpes zoster virus. Treatment for viral infections includes the topical application of Acyclovir (Zovirax) or Valacyclovir (Valtrex) (Griffiths and Boyle, 1993).

Other common oral problems that a nurse may encounter may include Halitosis (bad breath) which may be a result of food debris in the mouth, plague deposits, dirty dentures and damaged or diseased teeth. Regular oral hygiene can help to alleviate this condition (Jones, 1998). Xerostomia is dryness to the mouth due to the failure of the salivary glands; the salivary glands may fail for the following reasons, chemotherapy, radiotherapy, and continuous use of oxygen or the presence of a nasogastric tube (Jones, 1998). Salvia substitutes, sipping water and mouth rinsing can help to alleviate this condition (Turner, 1996).

Mouth care assessment

It is important that a patient receives an oral assessment as soon as possible, making a baseline assessment allows a nurse to monitor the status of the oral cavity and the effectiveness of oral care can then be judged (Jones, 1998). The initial assessment should be carried out with an appropriate light source such as a torch (Moore, 1995), so the whole cavity can be inspected closely. The cavity should be examined and observations made on the following, moisture level, colour and texture, the nurse should also note the presence of the following, plaque, debris, cuts and bleeding (Clarke, 1993). A nurse should also be looking for swelling, soreness and ulcers; a point to note is that some adverse drug reactions can manifest themselves in the mouth appearing as oral lesions causing extreme discomfort. These reactions may even damage teeth and gums (Rogers, 1998). It is therefore important for a nurse to carry out an accurate initial assessment recording the condition of the oral cavity so progress can be monitored.

Mouth care and the seriously ill patient

A normal healthy mouth contains harmless florae that combine with salivary proteins and glycoproteins to form water-insoluble plaque, the actions of mastication (Chewing) facilitate the movement and production of salvia within the oral cavity. Salvia contains components that are important in the suppression of bacterial and fungal colonization so these movements have an antibacterial and antiplaque role (Stiefel, Damron, Sowers and Valez, 2000). For the seriously ill patient the absence of salvia production and movement can have serious consequences, if left undisturbed for as little as three days an intubated or unconscious patient could have hundreds of bacterial species (Predominantly gram-negative) colonising residual plaque. If tissue destruction occurs at the base of the tooth or the gum line then these infections can pass to the circulatory system (Kite and Pearson, 1995), which then places the patient at risk to further complications.

Within the Intensive Care (ICU) setting Ventilator-Associated Pneumonia (VAP) is the predominant nosocomial infection with a mortality rate of between 54% and 71% (Grap, Munro, Ashitiani and Bryant, 2003). The risk factors for VAP include the presence of an endotracheal tube, as it allows direct entry of bacteria into the pulmonary tract and dental plaque. Micro organisms are concentrated in dental plaque and can include organisms such as Methicillin Resistant Staphylococcus Aureus (MRSA) or Pseudomonas Aeruginosa. The process of oral colonization usually precedes pulmonary colonization which can then lead to VAP; oral hygiene reduces the plaque which in turn reduces the pool of organisms that can pass to the lungs along the endotracheal tube, it is therefore essential to prevent this occurrence by providing the seriously ill patient with regular oral health care (Grap et al, 2003). Unfortunately despite the importance of oral care being reported (Adams, 1996 and Nesley, 1986), little evidence exists as to the effects of oral care interventions on the critically ill patient. Evidence based protocols are not available as oral care appears to be directed at patient comfort rather than the control of hazardous microbes (Grap et al, 2003). Equipment used for mouth care

Most of the research reviewed for this essay recommends the use of a toothbrush as the only effective means to remove dental plaque (Adams, 1996, Jones, 1998, Kite and Pearson, 1995 and Moore, 1995). Research also suggests that a paediatric toothbrush is the brush that should be used as it is smaller and softer and less likely to cause trauma to the oral cavity (Clarke, 1993, Evans, 2001, Griffiths and Boyle, 1993). It is curious that despite documented evidence that exists as to the benefits of the paediatric toothbrush, most ICU¡¦s and Critical care areas still employ adult size toothbrushes (Grap et al, 2003). Toothpaste used in conjunction with a toothbrush is accepted within the literature as the most effective method of oral care (Griffiths and Boyle, 993 and Holmes, 1996), the fluoride within the toothpaste helps to prevent tooth decay and can reduce tooth sensitivity (Jones, 1998).

Foam sticks are useful for providing the patient with gentle mouth care, the oral cavity needs to be kept moist and research indicates that the foam stick is an ideal tool to achieve this (Clarke, 1993 and Jones, 1998). However some studies reveal that the foam stick is regularly used by nurses to remove plaque (Holmes, 1996), this is in contrast to the research findings that clearly reveal that foam swabs are ineffective in this role (Holmes, 1996 and Pearson, 1995).
Other equipment that may be used includes water for rinsing and moisturising the mouth, water is the cheapest and safest agent to use. With a pH of 7 it cause the least disruption to the oral ecosystem (Gooch, 1985 cited in Clarke, 1993), normal saline without preservatives may also be used. A syringe or continuous low suction can also be employed to remove excess moisture in patients who are unable to remove it for themselves, for unconscious patients or patients who could bite an oral airway may be inserted and twisted to allow access to the mouth and prevent the patient biting (Evans, 2001). Vaseline or lip balm may also be required to apply to chapped lips and of course the nurse will need a pair of gloves to prevent the risk of infection to both patient and nurse (Clarke, 1993).

Mouth care procedure

After a baseline assessment, mouth care should be carried out daily, it is possible to approach oral care in stages:-

Stage 1
If it is possible the procedure should be explained to the patient to ensure he or she understands what is about to happen to them and why. For infection control purposes the nurse should be wearing gloves before any procedure is carried out. With a paediatric sized toothbrush and a small amount of toothpaste the nurse should then begin at the front of the mouth, the toothbrush should be sideways against the teeth with the bristles pointing to the roots of the teeth. A simple sideways motion is required and should be repeated on the lower jaw, tongue, gums and inner surfaces (Jones, 1998).

Stage 2
The mouth should be rinsed thoroughly with water using foam sticks or even gauze squares. If the toothpaste is not rinsed away then any residue can have a drying effect on the oral mucosa (Clarke, 1993), dry tissue is subject to infection (Griffiths and Boyle, 1993), so it is essential that all residues of toothpaste are removed.

Stage 3
All excess moisture needs to be removed from the patient¡¦s mouth, this can be achieved by using continuous low suction or the patient can spit the excess fluid into a receptacle if they are able to do so. A patient may prefer to use an antiseptic mouth wash instead of water; the rinsing motion will help to remove any loosened debris and toothpaste and will help to make the mouth taste fresher. Patients who are at risk of aspiration should have this procedure carried out on their side (Clarke, 1993), and consequently it may require two people to carry out this task.

Stage 4
The patient¡¦s mouth needs to be kept moist, this can be achieved with water and foam sticks. The frequency of mouth moisturising depends on the patients condition (Evans, 2001). Other products that may be used include Glandosane which is a synthetic salvia used to moisten the mucosa, tongue and throat. This product is delivered via an aerosol spray and is used when and if required.

Stage 5
After the above mentioned procedures have been carried out the nurse may then turn their attention to the external surfaces of the mouth. Lip balm or soft paraffin may be applied to areas of soreness or chapped lips.

It is important to remember that mouth disease can occur in patients who are dentate (having all or some of their natural teeth) and edentulous patients (without natural teeth) (Jones, 1998). Edentulous patients should have their dentures scrubbed with soap and water before they are left to soak in an appropriate cleaning agent, before re insertion the dentures should be rinsed in clean water and when not in use should be stored in a marked container with clean water. Good oral care does not only include the cleaning of teeth, attention needs to be paid to the oral mucosa, gums and teeth. Patients who are alert and orientated should be encouraged to perform their own oral care with the support of the nurse when and if required (Walton and Miller, 2001). Whenever a patient is unable to carry out this self care practice then the nurse must make every effort to augment oral hygiene on a daily basis. However there seems to be little research into the frequency of oral hygiene, regular mouth care is regarded as very important and it is argued that the frequency of care is sometimes more important that the equipment used (Holmes, 1996). Dental decay occurs when debris and plaque has been in place for 24 hours or more, debris and plaque are deposited after a person has eaten so brushing the teeth and oral cavity after each meal should reduce the risk of any oral complications (Mallett and Bailey, 1996).

For most patients a simple and effective way to achieve oral health is tooth brushing, regular tooth brushing as part of regular oral hygiene and basic nursing care can be very effective in preventing oral complications. The control and removal of dental plaque and the assessment and monitoring of the oral cavity appear to have significant implications for nursing practice and patient outcomes. The use of a paediatric toothbrush for the effective control of plaque is, according to the evidence, the tool of choice. Despite the research to support this many clinical areas still use normal adult toothbrushes for dental care and some areas even use foam sticks for oral care even though the evidence suggests that they are ineffective in this role (Holmes, 1996 and Pearson, 1995).
The aims of mouth care are to maintain a healthy and clean oral cavity, keep the oral mucosa moist, prevent build up of plaque, prevent or detect infection, prevent chapped or broken lips and to promote comfort, dignity and well being for the patient (Clarke, 1993). These aims can only be met if a patient receives regular mouth care and assessment. Mouth care should be daily and should be planned on an individual¡¦s assessment, a baseline assessment should be carried out on admission so that change can be monitored and the effectiveness of oral care can be judged (Clarke, 1993).
Mouth care is an important aspect of critical care and non critical care, good oral hygiene is practised by most people at home with just a toothbrush, toothpaste and water. In most cases this is all that is needed to do the same for our patients.

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