This course aims to provide an overview of oral care, its clinical significance, and best practices to help nurses provide optimal care, improve patient education, and enhance patient outcomes.
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Oral Hygiene for Nurses
Disclosure Statement
This course aims to provide an overview of oral care, its clinical significance, and best practices to help nurses provide optimal care, improve patient education, and enhance patient outcomes.
Upon completion of this course, learners should be prepared to do the following tasks.
- 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 or at end of life.
- Discuss nursing implications in oral care.
Key Terms
- Dental caries: areas of decay in teeth caused by the breakdown of tooth enamel.
- Periodontitis: severe gum infection or gum disease that can lead to tooth and bone loss (Bhambri, 2020).
- Trismus: reduced ability or loss of ability to open the jaws caused by spasms of mastication muscles (Gondivkar et al., 2021).
- Gingivitis: inflammation of the gingival tissue, characterized by redness in gum margins, swelling, and bleeding with brushing (Bhambri, 2020).
- Dental plaque: a complex biofilm found on the surface of the teeth where bacteria colonize (Zhao et al., 2020).
- Xerostomia: decreased or absent saliva production (Choi et al., 2021).
- Hospital-acquired pneumonia (HAP): pneumonia that occurs 48 hours or more after admission to the hospital and does not appear to be incubating at the time of admission.
- Ventilator-associated pneumonia (VAP): a type of HAP that develops in intubated patients on mechanical ventilation for more than 48 hours, including occurrence within 48 hours of extubation (Klompas, 2023).
The integration of oral health as a pillar of health care is necessary for the prevention and management of chronic diseases. However, oral health competencies are lacking when it comes to the training of primary care providers, nurses, and other interdisciplinary care team members. In a survey of primary care specialties, including nursing, pediatrics, and family practice, it was found that most health care workers reported only 1 to 3 hours of training in their schooling related to oral care. Poor oral health and dentition correlate to cardiovascular disease, diabetes, and more. Oral care, therefore, should be a foundation of health assessment in primary and acute care facilities (Donoff & Daley, 2020).
Over 600 kinds of micro-organisms, including bacteria, fungi, and viruses, are present in the human mouth. These organisms colonize on the surface of teeth and oral mucosa, particularly on dental plaque. The oral cavity may harbor Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus, Enterobacter, and other potentially harmful bacteria. Gram-negative bacteria can multiply rapidly, potentially tripling in as little as 3 to 6 hours (Warren et al., 2019).
A key defense mechanism against pathogens that may colonize in the mouth is saliva. Saliva production has a profound influence on the balance of micro-organisms in the mouth. Saliva has a mean pH of 6.75 to 7.25, favoring the growth of beneficial micro-organisms. It continuously bathes the teeth and mucous membranes, and the presence of proteins and glycoproteins in the saliva helps to remineralize tooth enamel. The presence of secretory immunoglobulin A (sIgA) in saliva prevents the colonization of harmful bacteria on surfaces of the mouth, along with polypeptides, cystatins, and other active proteins that control levels of yeast and other microbes. Given these beneficial properties, a decrease in salivary flow can disrupt homeostasis in the mouth, resulting in dental caries, tooth loss, periodontal diseases, and even endodontic infection (Bhambri, 2020). Patients who are sedated and intubated have significantly reduced salivary flow, leading to xerostomia (Choi et al., 2021). Xerostomia can also be caused by several common medication classes, such as opioids, diuretics, corticosteroids, antidepressants, anticholinergics, antihistamines, antihypertensives, muscle relaxants, and sedative or anxiolytic agents (Talha & Swarnkar, 2023).
Research demonstrates an acute deterioration of oral health after admission to a critical care unit, especially in cases where patients require endotracheal intubation. Endotracheal tube (ETT) insertion and critical illness reduce oral immune defenses, can cause trauma to the mouth or upper airway, increase the occurrence of gingivitis, and decrease overall moisture in the mouth. In addition, the presence of an ETT makes oral care more difficult as areas of dental plaque buildup become more difficult to reach. Dental plaques are resistant to chemical intervention once they are formed, so mechanical disruption, ideally in the form of toothbrushing, is the most effective intervention. Oral care should include the use of mouth rinse, moisturizing gel, and a swab or toothbrush to remove plaque and debris from the oral cavity (Zhao et al., 2020).
Hospital-acquired pneumonia (HAP) is the most common nosocomial infection, impacting about 1% of patients and up to 10% of patients requiring mechanical ventilation (Lauritano et al., 2019). HAP may form when harmful bacteria colonized on dental plaque are aspirated into the lungs. This can even happen in healthy adults, and in cases of aspiration, patients are up to six times more likely to develop HAP (Giuliano et al., 2021). A study conducted by Warren and colleagues (2019) showed that implementing a nurse-driven oral care protocol, recognizing oral care as a high-priority and high-impact intervention, decreased the overall incidence of HAP, as well as improved pneumonia outcomes, and decreased patient mortality. Another study by Giuliano and colleagues (2021) showed nearly three times as many cases of HAP in the control group as compared to the intervention group when an enhanced oral care protocol was implemented.
Oral Care Basics
Ensuring good oral health in critically and chronically ill patients is imperative to reduce the risk of health care-associated infections. It is essential for preventing and controlling oral conditions and other infectious diseases, consequently impacting patient outcomes (Zhao et al., 2020). Patients who use tobacco and alcohol regularly or cannot brush their teeth are at increased risk for poor oral health. Oral care can also affect the patient’s quality of life. In older adults residing in long-term care (LTC) facilities, losing teeth and halitosis (bad breath) can lead to isolation due to embarrassment, malnutrition, and communication difficulties (Donoff & Dale, 2020).
Because compliance with oral care policies remains low, The Joint Commission and the American Dental Association developed educational materials to improve this. Major barriers to high-quality oral care 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 training 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 (Quinn & Baker, 2015). Engaging family
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members in oral care and daily care practices improves patient acceptance of these practices and may even provide an external prompt to ensure oral care is being completed as necessary (Lauritano et al., 2019).
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 may vary by patient population and setting, but manual removal of plaque through brushing, flossing, and/or mouth swabs is a critical part of oral care interventions. Mouth rinse, toothpaste, and gel can be used, and using suction to remove excess secretions reduces the risk of aspiration (Zhao et al., 2020).
Hospitalized Patients
Health care organizations should invest in developing evidence-based oral care protocols for all levels of care, not just critically ill patients. 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 (Giuliano et al., 2021). Nurses are responsible for evaluating each patient’s oral mucosa and gag reflex and determining the appropriate method for oral care. The patient’s gag reflex directly affects their risk for aspiration. Clean gloves should be worn when assessing the oral cavity or performing oral hygiene. The oral cavity assessment should include an evaluation of the lips, teeth, buccal mucosa, gums, palate, and tongue; a penlight and tongue depressor are often required (Perry et al., 2018). Dentures should be removed before assessing the oral cavity (Quinn & Baker, 2015). Any potential dental problems should be explicitly documented within the patient’s medical record, communicated with the health care team, and considered when formulating the individualized care plan (Perry et al., 2018).
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).
Figure 1
Dental Caries
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).
Figure 2
Geographic Tongue
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 (Centers for Disease Control and Prevention, 2021).
Figure 3
Oral Candidiasis
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 mouthwash
- An emesis basin
- Bath towels
- Water-based lip moisturizer (Perry et al., 2018; Quinn & Baker, 2015)
Guidelines recommend using 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 mucous membranes. Oral hygiene should be performed four times daily in hospitalized patients (Quinn & Baker, 2015). Chlorhexidine (CHG) helps prevent infection by creating a film that adheres to the teeth and prevents the growth of gram-positive organisms (Shea, 2021). However, CHG has been shown to significantly alter the salivary microbiome and may kill bacteria, fungi, and viruses that are essential for oral and systemic health (Brookes et al., 2021). In randomized controlled trials, the impact of CHG oral care in non-ventilated patients is not clear (Lauritano et al., 2019). It has long been hypothesized that using an antiseptic like CHG may reduce the bacterial load of the mouth, therefore reducing instances of HAP. While there is low-quality evidence that CHG may reduce cases of VAP, there is no evidence correlating it to reduced mortality (Zhao et al., 2020). For this reason, the 2022 update regarding strategies to prevent HAP in acute-care hospitals recommends daily toothbrushing in adults and pediatric patients with teeth (gauze if no teeth yet). The Society for Health care Epidemiology (SHEA) and the Infectious Disease Society of America (IDSA) recommend against the use of oral care with CHG due to a lack of evidence that this practice decreases VAP rates. In preterm infants, the use of sterile water or maternal colostrum is recommended (Klompas et al., 2022).
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 to 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 reports 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 LTC 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 some patients simply may not be able to communicate toothaches or sensitivity (Donoff & Daley, 2020).
The procedures for oral hygiene in LTC residents mirror those described above for acutely hospitalized patients in most facilities. 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. 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 may cause poor denture retention, 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 (Treister & Villa, 2022).
Special Considerations for Cancer Patients
Chemotherapy attacks rapidly dividing cells, and because 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 be associated with 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 2 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 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 2 to 3 hours while awake, the patient should rinse their mouth with ¼ teaspoon of baking soda and ⅛ 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 (1 teaspoon of table salt in 1 quart of water)
- Salt and soda (½ teaspoon of salt and 2 tablespoons of sodium bicarbonate in 1 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 3 liters
- Consuming a high-protein diet
- Removing partial or full dentures whenever possible, especially if ill-fitting or when oral sores are severe (Wilkins, 2017)
The World Health Organization (WHO) Oral Mucositis Scale can measure and document mucositis (see Table 1).
Table 1
World Health Organization Oral Mucositis Scale
Grade | Clinical Features |
0 | No oral mucositis |
1 | Soreness, erythema |
2 | Oral ulcers, solid foods tolerated |
3 | Oral ulcers, liquid diet only (due to mucositis) |
4 | Oral ulcers, alimentation impossible (due to mucositis) |
(Wilkins, 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. VAP is a threat for all mechanically ventilated patients, with increased occurrence the longer a patient is intubated. Artificial airways become colonized with bacteria, increasing the chance of developing pneumonia (Klompas, 2023; Lauritano, 2019).
Infection can be prevented through strict adherence to infection control. The focus for VAP prevention was initially placed on aspiration; however, many studies show that oral care improvement significantly contributes 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 are order sets designed to prevent VAP. They usually include orders to perform oral care per agency policy, such as using an antimicrobial rinse, 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 sodium chloride solutions. Oral care frequencies range from twice daily to every 2 hours. 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 the 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. 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 2022 by the Society for Health care Epidemiology of America. Routine oral care in the form of toothbrushing without CHG is considered essential practice in ventilated adults. Meta-analyses of CHG use for oral care, as opposed to toothbrushing, showed a low likelihood of benefit and even potential harm to patients. Therefore, oral care with CHG to prevent VAP is not recommended. 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., 2022).
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).
Dentures and partials should be removed and placed in a denture cup with a denture cleaner. CHG 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., 2022).
Oral Care Nursing Implications
A nurse-led oral care program can reduce HAP rates by up to 60% and save millions of lives per 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. Because 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.).
References
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Zhao, T., Wu, X., Zhang, Q., Li, C., Worthington, H., & Hua, F. (2020). Oral hygiene care for critically ill patients to prevent ventilator‐associated pneumonia. Cochrane Database of Systematic Reviews, 12. Article CD008367. https://doi.org/10.1002/14651858.cd008367.pub4