CHHS18/068

Canberra Hospital and Health ServicesClinical Procedure Oral Hygiene Contents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Alerts.........................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Background.............................................................................................................2

Section 2 – Attending Oral Hygiene..........................................................................................3

Implementation........................................................................................................................ 5

Related Policies, Procedures, Guidelines and Legislation.........................................................5

References................................................................................................................................ 6

Search Terms............................................................................................................................ 6

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Purpose

The purpose of this document is to provide guidelines to assist in the provision of oral hygiene including; maintaining intact well hydrated oral mucosa, preventing infection and dental caries by removing food particles and biofilm from teeth and gums and promoting patient comfort and assisting appetite.

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Alerts

Oral hygiene is a strong predictor of aspiration pneumonia in patients with dysphagia.

See: Speech Pathology Management of Dysphagia Standard Operating Procedure on the policy register.

Note: Caution with patients with a low platelet count of <20, as vigorous brushing may cause bleeding. Caution with patients who have had facial reconstruction surgery, facial fractures or fractured mandible.

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Scope

This procedure applies to the following staff working within their scope of practice: Medical officers, Nurses and Midwives Allied health officers Allied health assistants Dental practitioners Dental assistants Students under direct supervision.

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Section 1 – Background

Poor oral hygiene is associated with conditions of gingivitis, dental caries, halitosis, xerostomia, chest infections and pneumonia.

Risk factors: certain medications and predisposing conditions can put patients at increased risk of poor oral hygiene. Dependent, dysphagic, critically or terminally ill people are particularly vulnerable. Risk factors include:

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Age – older people may have difficulty managing their oral care due to problems with dexterity and eye sight. Additionally, denture wearers are at an increased risk as the acrylics within the dentures provide favourable conditions for Candida Albicans.

Mental Health/Neurological Problems/Cognitive impairment/Mild to advanced dementia – those with these conditions may not have the awareness of the need or importance of oral health care and may be unable to express that they are experiencing problems.

Poor diet – inadequate dietary and fluid intake reduces the secretion of saliva while a lack of sufficient vitamins and minerals can predispose patients to infection.

Medical conditions – immunosuppression related to conditions such as HIV, leukaemia, diabetes and cancer and their associated treatments, can impact on hydration and natural flora of the oral cavity putting patients at risk of infection.

Medication – medication altering the natural flora by reducing protective salivary secretion include anticholinergics, antiemetics, antibiotics, diuretics, antihypertensives, anticonvulsants, antidepressants, antispasmodics, opiate analgesics, steroid therapy, chemotherapy and oxygen therapy.

Unconscious/intubated patients – the oropharynx of critically ill patients can become colonised with potential respiratory pathogens 4. Oral care has been shown to reduce oropharyngeal bacteria and subsequent pneumonia. Mouth breathing is common in unconscious patients placing them at risk of xerostomia.

Dysphagia (swallowing impairment) – modified diet and fluid may lead to inadequate dietary and fluid intake/poor diet

Palliative patients- may not have the awareness of the need or importance of oral care and may be unable to express that they are experiencing problems.

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Section 2 – Attending Oral Hygiene

1. Initial assessment should include: History of previous dental care Previous oral problems Age and risk factors including dentures Current nutritional status Current treatment and any proposed clinical management Usual oral hygiene practices Level of assistance required for oral hygiene Whether patient has his/her own toothbrush and toothpaste.

2. Minimum equipment is to include: Alcohol based hand rub (ABHR) Tooth mug/bowl Towel Toothpaste Soft brush and appropriate storage container.

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3. Additional equipment can include: Oral swabs Sodium bicarbonate or diluted Cepacol or prescribed water-based mouthwash Lip balm/Peppermint lip cream AquaE spray or equivalent oral hydration product Tongue depressor Torch Personal protective equipment (PPE) including safety goggles or shield Clinical waste receptacle.

4. Prior to Attending Oral Hygiene: Attend hand hygiene before touching the patient Ensure privacy Explain the process and purpose Obtain verbal consent Confirm allergies Refer to patient’s individualised mouth care plan (if one has been developed by the oral

health therapist).

5. Attending Oral Hygiene Ensure the patient is placed in an upright/fowlers position. Attend hand hygiene by either hand washing or using ABHR. Don PPE, as per Healthcare Associated Infection Procedure on the policy register. Assess the oral cavity. Allow or assist the patient to clean teeth/dentures or clean and massage the gums,

teeth, tongue with sodium bicarbonate or mouthwash soaked swabs. Place dentures in a denture cup clearly labelled with the patient’s details when not in

use. Ensure the patient’s mouth is clear of excess toothpaste (encourage patient to spit in a

disposable cup). Rinsing after cleaning is not recommended. Apply lip balm and aerosol spray as indicated. Replace dentures as appropriate. Rinse toothbrush and remove excess water with disposable paper towel. Store in an

appropriate container that allows bristles to dry. Discard single use equipment into clinical waste receptacle. Attend hand hygiene by hand washing or using ABHR Document in patient’s clinical record:

o Description of the oral cavityo Type of mouthwash and toothpaste usedo Signs of skin breakdown or infection

Report any concerns to the Medical Officer and/or visiting oral health therapist where appropriate.

6. Specific Oral Hygiene Problems/Interventions

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Stomatitis General oral hygiene 4 hourly and as required (PRN)

Gingivitis/glossitis Brushing/mouthwashes 4 hourly and PRNXerostomia Mouthwashes/Aerosol 4 hourly and PRNUlceration Mouthwashes/massage 3 times a day/after mealsHalitosis Brushing/mouthwashes 4 times a day and PRN

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Implementation

To ensure consistency and sustainably in performing adequate and timely oral hygiene, strong communication systems to the affected staff will be implemented through: Education sessions by Clinical Development Nurse, Registered Nurse level 2&1 and

visiting oral health therapist Quality improvement Laminated poster Oral hygiene month awareness This procedure will be available to all staff on the policy register.

Note: Speech Pathologists are responsible for education packages on dysphagia rather than oral care.

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Related Policies, Procedures, Guidelines and Legislation

Policy ACT Health Waste Management Policy Nursing and Midwifery Continuing Competence Policy Consent and Treatment Policy

Procedure Healthcare Associated Infection Procedure Speech Pathology Management of Dysphagia Procedure Patient Identification and procedure Matching Procedure

Legislation Health Records(Privacy and Access) Act 1997 Human Rights Act 2004 Work Health and Safety Act 2011

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References

1. Hand Hygiene Australia: 5 moments of Hand Washing.2. Arkel S and Shinnick A (2003). Update on Oral Candidosis. Nursing Times, 99:48, 52-53.3. Clay,M (2000). Oral Health in Older People. Nursing Older People, 12:7, 21-254. Furr, A et al (2004). Factors Effecting Quality of Oral Care in Intensive Care Units. Journal

of Advanced Nursing, 48:5, 454-4625. Joanna Briggs Institute for Evidence Based Nursing (1998). Prevention and Treatment of

Oral Mucositis in Cancer Patients. Vol 2, Issue 3:1-66. World Health Organisation (WHO) Guidelines on Hand Hygiene in Healthcare.7. www.nursingandmidwiferyboard.gov.au/Codes-andGuidelines.aspx

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Search Terms

Oral Hygiene, Dysphagia, Gingivitis, dental caries, halitosis, xerostomia, Oral Hygiene Problems, Oral Hygiene Interventions, mouth care, teeth, oral

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval 21/02/2018 Complete Review Linda Kohlhagen, ED

RACCCHHS Policy Committee

This document supersedes the following: Document Number Document NameTCH11:042 Oral Hygiene

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