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ORAL HYGIENE: ASSESSMENT AND MANAGEMENT

Guideline Statement:
These guidelines should guide clinical practice related to routine oral care specifically focusing
on appropriate assessment and interventions for patients.

Related Clinical Documents:

Oral Mucositis- Prevention and Management

Objectives
 To promote standardised oral assessment and oral hygiene care
 To promote patient comfort and quality of life
 Maintain and optimise a clean and healthy oral cavity

Scope
Clinical assessment and management of oral hygiene for inpatients across all sites.

Definitions
Oral Cavity: refers to part of the mouth including:
 Lips
 Lining inside the cheeks and lips
 The front of the tongue
 Upper and lower gums
 Floor of the mouth
 Bony roof of the mouth (i.e. the hard palate)
 Small area behind the wisdom teeth (1)

Xerostomia: or dry mouth is characterised by a reduction in salivary flow in the oral cavity. This
can effect oral health causing a sore throat, impairing chewing and swallowing, alter taste and
dental decay which can ultimately affect quality of life (2).

Oral Candidiasis: a yeast infection of the mouth and throat caused by the fungus Candida
albicans accumulating on the lining of the mouth. Candida is a normal organism in the mouth,
but sometimes it can overgrow and cause symptoms. Oral candidiasis causes creamy white
lesions, usually on the tongue or inner cheeks. Sometimes oral thrush may spread to the roof of
the mouth, the gums or tonsils, or the back of the throat (3).

Sialorrhoea and hypersalivation: refers to unintentional loss of saliva from the mouth (drooling).
Hyper salivation refers to an increase in or excessive saliva production. These conditions can
cause inflammation, dryness and soreness of the skin around the mouth (4).

Oral Mucositis: is defined as the disruption of the integrity and function of the mucosal lining of
the gastrointestinal tract ranging from mild inflammation to deep ulceration. It affects some 35-
40% of patient receiving cytotoxic chemotherapy, the incidence being higher still in patients
having radiation therapy as part of their treatment regimen or undergoing autologous/allogeneic
peripheral blood stem cell transplants (5).

Halitosis: (bad breath) is mostly caused by sulphur-producing bacteria that normally live on the
surface of the tongue and in the throat

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Acronyms
NBM: Nil by mouth

Guidelines
1. Responsibilities
Medical staff, nursing staff, nursing assistants, speech pathology and pharmacy all have a
crucial role in assessing and managing oral hygiene (6)
1.1 Medical staff
 Diagnose specific oral health conditions
 Prescribe appropriate medication
 Liaise with Pharmacy, Nursing and Speech Pathologist as appropriate
1.2 Nursing staff/ Nurse assistants
 Assist patient to perform oral hygiene
 Assess, implement and monitor the effectiveness of oral hygiene regimes
 Educate patients and families on best oral care practice
 Liaise with Medical, Pharmacy and Speech Pathologist as appropriate
1.3 Speech Pathology
 Identify oral health issues during routine swallowing assessment
 Suggest oral care plans for patient in conjunction with medical and nursing staff
 Implement individualised oral care plans for all patients with dysphagia (7)
 Educate patients and families on the importance of oral care and how to perform
oral care
 Liaise with Medical, Nursing and Pharmacy as appropriate
1.4 Pharmacy
 Assist medical staff with appropriate treatment options for specific oral health issues
 Educate patients and families on medication use on discharge
 Supply prescribed medication if not available on imprest

2. Assessment
Thorough assessment of oral cavity is required on every patient on admission. The
assessment should include a discussion with the patient about their current oral hygiene and
potential oral problems. As appropriate, an exploration of the functional impact as a result of
changes to oral hygiene such as difficulties swallowing, speaking, food restrictions, oral
dryness, pain, anxiety and worry about their current oral hygiene is important to guide
management (12). The oral cavity should be pink, moist and clean, teeth should be intact
and dentures fitting well. Assessment includes observing lips and all structures of the oral
cavity to identify any abnormalities in the following (8)
 Saliva (e.g. xerostomia or sialorrhea)
 Mucosa (e.g. coating, mucositis, inflammation, candida)
 Trauma (e.g. oedema and bleeding)
 Halitosis
 Dental condition (e.g. pain, dental decay, dentures, bleeding gums)

3. Management
The following general themes emerge from the literature:
 Frequency is more important than the products used (9).
 Oral care needs of patients are identified on an individual basis taking into account the
patients’ self-care abilities (10).
 Reassessment of the oral cavity should occur at a minimum of twice daily to ensure
ongoing care is maintained (8).
 Patients should have individualised oral hygiene plans and physical assistance should
be provided by staff appropriate to their level of ability (8).
 The clinical management of oral problems should be carried out as a team (12)
 Patients and their families require education on effective oral hygiene (13)
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3.1 Management Options

Caution is advised for patients with swallowing difficulties with some of the following
strategies. Consultation with speech pathology is recommended.
Basic  Brush teeth twice a day with fluoride toothpaste
generic  Clean tongue with a soft toothbrush or tongue cleaner
oral care  Rinse with water and/or antibacterial mouthwash
 Ensure dentures are fitting well to minimise inflammation
 Clean dentures at least twice a day using a denture cleaning solution and then
rinse under water (8)
 Floss daily
Oral  Brush teeth with fluoride toothpaste
coating  Rinse or swab oral cavity using alcohol-free mouthwash, e.g. sodium
bicarbonate solution
Candida  Topical or systemic application of antifungal medications (e.g. Nystatin
suspension, Fluconazole capsules), as prescribed by the medical team. Ensure
the patient does not eat or drink for 30 minutes post treatment of Nystatin oral
drops and amphotericin lozenges. Topical antifungal medication should be
administered for 7days; continue treatment for 2 to 3 days after symptom
resolves (2)
 Brush teeth with fluoride toothpaste and rinse mouth with water, as required.
Xerostomia  Review medication for possible contributing side effects of current medications.
& reduced  Apply an oral lubricant or artificial saliva (e.g. Biotene Oral Balance Gel) (8).
saliva  Rinse or swab oral cavity with alcohol-free mouthwash (e.g. sodium
bicarbonate solution – see attachment A) or alcohol-free commercially available
mouthwash as required
 Encourage chewing sugarless lollies or gum
 Apply lip balm as required
 Regular sips of water or ice chips
 Brush teeth with a dry mouth toothpaste
Excessive  Compensatory strategies (e.g. face towel, tissues)
Secretions  Occupational Therapy review patients positioning and posture (4)
 Speech Pathology review of swallowing strategies.
 Medication review of possible contributing side effects of current medication
 Medical review to consider use of anti-cholinergic medication
Oral See SVHM Oral Mucositis- Prevention and Management policy
mucositis
Thick/ropey  Regular sodium chloride 0.9% nebulisers
secretions  Sodium bicarbonate mouthwash solution
 Sodium chloride 0.9% swabs
 Increase fluid intake
 Other (not available at SVHM): dark grape juice &/or papaya enzyme tablets
Patients  4 hourly mouth care is required
who are  Twice daily tooth brushing with a small soft toothbrush
NBM and/or  Brush teeth in an upright position
have  For NBM patients use suction toothbrush if available (4) or swabs
dysphagia  Rinse or swab oral cavity using an antiseptic mouthwash (e.g. non-alcoholic
mouth wash)
 Rinse oral cavity with water
 NBM patients or patients on thickened fluids: ensure fluid not swallowed (e.g.
Swab moist but not wet)
 Apply lip moisturiser
 Regular use of an oral lubricant (e.g. Biotene Oral Balance gel)
Painful  Examine mouth for ill-fitting dentures, dental decay or infection. Refer to dentist.
Mouth
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 Topical analgesia (e.g. choline salicylate (Bonjela®), lidocaine (lignocaine) 2%

viscous)
 Medical review regarding systemic pain relief

References
1. Institute, National Cancer. National Cancer Institute. NCI dictionary of cancer terms viewed 01
Feb 2017
2. Palliative Care Expert Group, 2010. 'Gastrointestinal symptoms- oral symptoms' Therapeutic
Guidelines Palliative Care Version 3 pp231-234.
3. Curl, C & Boyle, C 2014, ‘Dysphagia and dentistry’, Dental Update, vol. 41, pp. 413-422.
4. EviQ 2016. Supporting Document - Oral Mucositis. EviQ cancer treatment online. viewed 1 Feb
2017
5. Yoon, M. N & Steele, C. 2012. ‘Health care professionals’ perspectives on oral care for long-
term care residents: nursing staff, speech-language pathologists and dental hygienists’,
Gerodontology, vol. 29, pp. 525-535.
6. Speech Pathology Australia 2012 ‘Dysphagia Clinical Guideline’. viewed 1st Feb 2017
7. Department of Health & Human Services, 2015. ‘Oral and dental hygiene: standardised care
process’. State of Victoria, Department of Health & Human Services.
8. Coleman, P 2002, ‘Improving Oral Health Care for the frail elderly: A review of widespread
problems and best practices’, Geriatric Nursing, vol. 23, no. 4, pp.189-199
9. Coker, E, Ploeg, J, Kaasalainen, S, & Fisher, A. 2013, ‘A concept analysis of oral hygiene care
in dependent older adults’ Journal of Advanced Nursing, vol. 69(10), pp. 2360-2371.
10. Choi, S & Kim, H 2012, ‘Sodium bicarbonate solution versus Chlorhexidine mouthwash in oral
care of acute leukemia patients undergoing induction chemotherapy: a randomized controlled
trial’, Asian Nursing Research, vol. 6, pp.60-66.
11. Dodd, M. J., Dibble, S. L., Miaskowski, C., MacPhail, L., Greenspan, D., Paul, S. M., et al
2000, ‘Randomized clinical trial of the effectiveness of 3 commonly used mouthwashes to treat
chemotherapy-induced mucositis’, Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology,
and Endodontics, vol. 90, pp. 39-47.
12. Venkatasalu, M. R., Murang, Z. R., Ramasamy, D., & Dhaliwal, J. S. (2020). Oral health
problems among palliative and terminally ill patients: an integrated systematic review. BMC oral
health, 20(1), 79.
13. Manchery N, Subbiah GK, Nagappan N, Premnath P. Are oral health education for carers
effective in the oral hygiene management of elderly with dementia? A systematic review. Dent
Res J (Isfahan). 2020 Jan 21;17(1):1-9. PMID: 32055287; PMCID: PMC7001561.

Authorship
Name: Position:

Primary Policy Author(s):

Patricia Ryan Clinical Nurse Consultant

Helen Leousis Senior Speech Pathologist

Others Consulted, including Committees:

Emily Brasacchio Admissions Co-ordinator

Dr Jennifer Weil Palliative Care Clinical Advisory Committee (PCCAC)

Kathryn McKinley Speech Pathology Manager

Barbara Harthen Senior Speech Pathologist

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Head of Department Responsible for policy:

A/Prof Mark Boughey Director, Palliative Care Services

Appendix A
Sodium bicarbonate mouthwash solution:

 Use for patients with dry and/or unclean oral cavities.

 It is non-irritating, neutral tasting, and helps maintain moisture of oral mucosa and reduce
the risk of secondary infection (11).

 It is an effective cleansing agent due to its ability to dissolve mucous and break down
sputum and debris (11).

 It acts to increase the pH of saliva, in order to suppress the growth of bacteria (12).

 It can be prepared by dissolving half a teaspoon of sodium bicarbonate or ‘baking

soda’ in 250mL of water.

 Tap water is not sterile; therefore any unused mouthwash should be discarded within 24
hours.

 Rinse oral cavity vigorously with sodium bicarbonate mouthwash, do not swallow
(swallowing will cause carbon dioxide production in stomach).

 In the NBM patient or patient with dysphagia, use on swabs and apply throughout the oral
cavity.

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