Skill 7-3

Assisting the Patient With Oral Care

Adequate oral hygiene care is imperative to promote the patient's sense of well-being and comfort, and prevent deterioration of the oral cavity (Kisely, 2016; Riley, 2018). Poor oral hygiene contributes to the colonization of the oropharyngeal secretions by respiratory pathogens. Diligent oral hygiene care can improve oral health and limit the growth of pathogens in the oropharyngeal secretions, decreasing the incidence of aspiration pneumonia, community-acquired pneumonia, nonventilator health care-associated pneumonia (NV-HAP), and ventilator-associated pneumonia (VAP) (American Association of Critical-Care Nurses [AACN], 2017; Chick & Wynne, 2020; Jenson et al., 2018; Quinn et al., 2020). Comprehensive oral care that includes thorough mechanical cleaning is an important part of care to achieve oral health outcomes for patients in all settings (Barbe et al., 2020; Chick & Wynne, 2020; Chicote, 2019; Gibney et al., 2019; Kisey, 2016).

The mouth requires care particularly during illness, but sometimes care must be modified to meet a patient's needs. If the patient can assist with mouth care, provide the necessary materials. Oral care is important not only to prevent dental gingivitis and caries , but also to improve the patient's self-image. Teeth should be brushed and flossed twice a day; the mouth should be rinsed after meals. If the patient is unable to perform oral hygiene, make certain that the mouth receives care as often as necessary to keep it clean and moist, as often as every 1 or 2 hours if necessary. This is especially important for patients who cannot drink or are not permitted fluids by mouth. Refer to Box 7-2 for suggestions to meet the oral hygiene needs for patients with cognitive impairments.

Delegation Considerations

The implementation of oral care may be delegated to assistive personnel (AP) as well as to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Toothbrush
Toothpaste
Emesis basin
Glass with cool water
Disposable gloves
Additional PPE, as indicated
Towel
Mouth rinse
Washcloth or paper towel
Lip lubricant (optional)
Dental floss or other interdental cleaner
Oral assessment tool, as indicated (Figure 1)

Assessment

Assess the patient's oral hygiene preferences: frequency, time of day, and type of hygiene products. Assess for any physical activity limitations. An oral assessment tool can assist with assessment of the status of the oral cavity, as well as help to determine the frequency and procedure for oral care (Figure 1). Assess the patient's oral cavity and dentition. Look for any inflammation or bleeding of the gums. Look for ulcers, lesions, and yellow or white patches. The yellow or white patches may indicate a fungal infection called thrush. Assess for signs of dehydration (dry mucosa) and dental decay. Look at the lips for dryness or cracking. Ask the patient if they are having pain, dryness, soreness, or difficulty chewing or swallowing. Assess the patient's ability to perform own care.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

ADL deficit
Impaired dentition
Aspiration risk

Outcome Identification and Planning

The expected outcome to achieve is that the patient's mouth and teeth will be clean, the patient will exhibit a positive body image, and the patient will verbalize the importance of oral care and demonstrate appropriate oral care skills.

Implementation

Action	Rationale
1. Perform hand hygiene and put on gloves if assisting with oral care, and/or other PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
2. Identify the patient. Explain the procedure to the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors. Explanation facilitates engagement in care.
3. Assemble equipment on the overbed table or other surface within the patient's reach.	Organization facilitates performance of the task.
4. Close the room door or curtains. Place the bed at an appropriate and comfortable working height (VHACEOSH, 2016).	Closing the door or curtains provides privacy. Proper bed height helps reduce back strain while performing the procedure.
5. Lower the side rail and assist the patient to a sitting position, if permitted, or turn the patient onto their side. Place a towel across the patient's chest.	The sitting or side-lying position prevents aspiration of fluids into the lungs. The towel protects the patient from dampness.
6. Encourage the patient to brush their own teeth according to the following guidelines. Assist, if necessary.
a. Moisten the toothbrush and apply toothpaste to bristles.	Water softens the bristles.
b. Place the brush at a 45-degree angle to gum line (Figure 2) and brush from gum line to crown of each tooth (Figure 3). Brush outer and inner surfaces. Brush back and forth across the biting surface of each tooth.	Facilitates removal of plaque and tartar. The 45-degree angle of brushing permits cleansing of all tooth surface areas.
c. Brush the tongue gently with toothbrush or tongue scraper (Mayo Foundation for Medical Education and Research [MFMER], 2019a) (Figure 4).	This removes coating on the tongue. Gentle motion does not stimulate the gag reflex.
d. Have the patient rinse vigorously with water and spit into emesis basin (Figure 5). Repeat until clear. Suction may be used as an alternative for removal of fluid and secretions from the mouth.	The vigorous swishing motion helps to remove debris. Suction is appropriate if the patient is unable to expectorate well.
7. Assist the patient to floss their teeth, if appropriate:	Flossing aids in removal of food and plaque and promotes healthy gum tissue (American Dental Association [ADA], n.d.b).
a. Remove approximately 18 inches of dental floss from container or use a plastic floss holder. Wrap most of the floss around one of the middle fingers. Wind the remaining floss around the same finger of the opposite hand, keeping about 1 to 1.5 inches of floss taut between the fingers.	The floss must be held taut to get between the teeth.
b. Insert floss gently between teeth, moving it back and forth downward to the gums.	Trauma to the gums can occur if floss is forced between teeth.
c. Move the floss up and down, first on one side of a tooth and then on the side of the other tooth, until the surfaces are clean (Figure 6). Repeat in the spaces between all teeth and the backside of the last teeth.	This ensures that the sides of both teeth are cleaned.
d. Instruct the patient to rinse mouth well with water after flossing.	Vigorous rinsing helps to remove food particles and plaque that have been loosened by flossing.
8. Offer a mouth rinse if the patient prefers or if use has been recommended.	Use of a mouth rinse can reduce bacteria and can help reduce plaque, gingivitis, tartar (hardened plaque) and also freshen breath. Anticavity rinses with fluoride help protect tooth enamel to help prevent or control tooth decay (ADA, 2019).
9. Offer lip balm or petroleum jelly.	Lip balm lubricates lips and prevents drying.
10. Remove equipment. Remove gloves and discard. Perform hand hygiene. Raise the side rail and lower the bed. Assist the patient to a position of comfort.	Removing gloves properly reduces the risk for infection transmission and contamination of other items. These actions promote patient comfort and safety.
11. Remove any other PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.

Evaluation

The expected outcomes have been met when the patient has received oral care, the patient has experienced little to no discomfort, the patient has reported their mouth feels refreshed, and the patient has demonstrated understanding of the reasons for proper oral care and appropriate oral care skills.

Documentation

Guidelines

Record oral assessment, significant observations, and unusual findings, such as bleeding or inflammation. Document any teaching done. Document procedure and patient response.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

While cleaning the teeth, you notice a large amount of bleeding from the gum line: Stop brushing. Allow the patient to gently rinse mouth with water and spit into emesis basin. Before brushing again, check the patient's most recent platelet level. Consider the use of a softer toothbrush to provide oral hygiene.
Patient has braces on their teeth: Braces collect food particles. Brush extra thoroughly. Reinforce the importance of using an appropriate interdental cleaner.

Special Considerations

General Considerations

Use a soft-bristled toothbrush with a small head even when the patient has no or few teeth. It is the only effective way to remove plaque and debris from the teeth, gums, and tongue.
Automatic toothbrushes, electric or battery operated, are simple to use and can be used to removing debris and plaque and clean the teeth effectively. Use of an electric toothbrush provide superior oral hygiene care when oral hygiene is provided by a caregiver (Vannah & Sammarco, 2019).
The use of chlorhexidine gluconate (CHG) as part of oral hygiene has been integrated into oral hygiene regimens and is available as an oral rinse, oral spray, and dental gel (AACN, 2017; de Camargo et al., 2019). The use of CHG as part of protocols for systematic oral care for critically ill patients has been shown to reduce risk of VAP (AACN, 2017; Chen et al., 2015).

Infant and Child Considerations

Begin brushing children's teeth as soon as they begin to come into the mouth and begin flossing when the child has two teeth that touch (American Dental Association [ADA], n.d.a).
Clean an infant's gums by wiping with a clean, damp cloth (ADA, n.d.a).
Young children should be supervised by an adult until they are between ages 7 and 10 years (Kyle & Carman, 2021); remind them not to swallow the toothpaste (ADA, n.d.a).
Use smaller amounts of fluoride toothpaste on the toothbrush for children: a smear (size of a grain of rice) for children younger than age 3 years and a pea-sized amount for children ages 3 to 6 years (ADA, n.d.a).

Older Adults

Physical limitations that may be associated with aging may interfere with the older adult's ability to perform adequate oral hygiene (Thomas, 2019). Pressurized water spray units (water flossing) are available to assist with oral hygiene to and can be a useful option for older adults and other patients who have trouble flossing by hand (American Dental Association [ADA], n.d.d).

EVIDENCE FOR PRACTICE

Oral Hygiene and Older Adults

Poor oral hygiene contributes to alterations in oral health and is associated with increased risk for aspiration pneumonia, community-acquired pneumonia, and other health concerns (Hata et al., 2019; Jenson et al., 2018; Müller, 2015; Quinn et al., 2020). Poor oral health in older adults compounds dental problems associated with aging. Adequate oral hygiene is essential to promote a sense of well-being and comfort and prevent deterioration of the oral cavity (Kisely, 2016; Riley, 2018).

Related Research

Red, A., & O'Neal, P. V. (2020). Implementation of an evidence-based oral care protocol to improve the delivery of mouth care in nursing home residents. Journal of Gerontological Nursing, 46(5), 33-39. https://doi.org/10.3928/00989134-20200316-01

This aims of quality improvement (QI) project were to determine if an evidence-based oral care protocol in addition to a staff oral care training program on a long-term care unit would increase staff knowledge of oral care in older adults and improve oral health outcomes in the long-term care residents. The Iowa Model of Evidence-Based Practice was used to guide this QI project. Staff knowledge, skills, and attitudes in oral care practices of older adults were assessed pre- and postintervention with a Likert scale questionnaire. Oral health status of the older adult residents (n = 10) was measured pre- and postintervention using the Oral Health Assessment Tool (OHAT). Nurses and certified nursing assistants (n = 29) attended four 30-minute oral health educational in-services centered on the significance of oral health in the older adult, basic mouth care, proper brushing techniques, denture care, oral care techniques, and standards of care. Caring for residents with disruptive behaviors and techniques to manage resistant care were also discussed. After completion of the educational sessions, an evidence-based Oral Care Protocol and daily oral care checklist were initiated, requiring oral care twice daily. Oral health outcomes of the residents were measured at three time points after 14 days of protocol use. Knowledge of oral health care improved significantly as evidenced by mean total pre-test score of 88.8 to mean total post-test score of 97.7 (p = .021). Statistically significant improvements (p = .001) were seen in oral health outcomes as measured by the OHAT. The authors concluded an oral health education intervention and evidence-based oral care protocol increases staff knowledge of oral care practices and improves oral health outcomes in older adults. The authors also suggested long-term care staff play an important role in improving oral hygiene of older adult residents through use of an evidence-based oral health protocol.

Relevance for Nursing Practice

Poor oral hygiene can contribute to poor oral health and oral diseases as well as other systemic health problems. By performing oral assessments, providing oral hygiene, and promoting tooth brushing and flossing, nurses and other health care providers can be instrumental in supporting optimal oral health outcomes and prevention of oral diseases in older adults.

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Skill 7-3

EVIDENCE FOR PRACTICE