Essential nursing care includes attention to your patients oral hygiene. This is something often forgotten in a busy emergency department. And I suspect from many other areas of the hospital.
Why so important?
- To protect the mucosal lining of the mouth from injury and infection.
- To alleviate halitosis.
- To minimise tooth decay and peridontal disease by removing plaque and debris.
- Improve overall patient comfort.
Just yesterday we had an elderly lady who we just could not get to keep any oxygen masks or nasal prongs on. She just kept swiping across her face and knocking them off.
After trying everything, I though as a long shot I would give her some mouth-care. Her mouth was dry dust.
And guess what? After a freshen up and a little Vaseline to her lips she slept like a baby.
- Improve oral intake.
There are groups of patients that are predisposed to mouth hygiene problems such as those with chronic obstructive pulmonary disease (due to persistent mouth breathing), patients that are nil by mouth and those with physical injury or intellectual impairment.
- Oncology patients: cytotoxic drugs or radiotherapy can cause damage to the cells lining the mouth leading to ulceration (mucositis).
- For those working in ICU or emergency, intubated patients are at increased risk of ventilator acquired pneumonia if a mouth full of incubating oral pathogens migrate to the lungs.
- Prolonged oxygen therapy dries the oral mucosa and can also lead to cracking and ulceration.
- Medications such as antibiotics, steroids, antihistamines and antidepressants can all depress the normal protective flora of the mouth resulting in bacterial growth or infection.
The most common oral infection is thrush (candidiasis) which appears as whitsh plaques on the mucosal lining.
Herpes simplex viral infections may also be seen, appearing as yellow lesions on the oral mucosa or lips.
Gloves. should always be worn when performing oral care on your patients. If there is any risk of them coughing or spluttering a face shield or eye protection should be considered.
Soft bristled toothbrush. using a fluoride toothpaste. I don’t need to tell you how to brush teeth. Take care not to poke around the posterior third of the tongue (or beyond) as it may stimulate the gag reflex.
Swabsticks. can be used to apply some of the solutions covered below. Again, watch that gag reflex.
Don’t forget to give the tongue a special treatment.
Large quantities of bacteria lurk on the dorsum of the tongue which can quickly become cracked and creviced providing an ideal habitat for them to expunge a jaw dropping halitosis gas of indoles, skatoles, polyamines, hydrogen sulfides, methyl mercaptans, allyl methyl sulfides and dimethyl sulfides.
The best way to clean the tongue is with a toothbrush or tongue scraper.
Normal Saline. can be used as a simple and effective mouth wash to remove debris and maintain a moist oral mucosa.
Sodium Bicarb. improves on normal saline by reducing halitosis (by increasing the pH of saliva and suppressing the growth of bacteria)… but it tastes pretty yuck.
Hydrogen peroxide. acts as a germicidal and is useful to remove crusty debris. Downside is that it may alter normal mouth flora increasing the possibility of thrush.
Chlorhexidine. has broad spectrum antimicrobial activity and is considered an effective mouthwash for reducing plaque and gingivitis.
Pineapple pieces. contain an enzyme called ananase which cleanses the mouth and have been suggested for use by radiotherapy patients with mouth problems.
Papaya pieces contain an enzyme called papain which breaks down the protein of saliva and can be useful in patients with thick or ‘Ropey’ secretions clagging up their mouth (Sodium Bicarb may also help with this).
A note on alcohol based mouthwashes Studies have shown that mouthwashes containing greater than 20% ethanol may cause keratosis, mucosal ulceration, gingivitis
and perhaps even an increased risk of oral cancers with prolonged usage.
Don’t forget the lips.
Finally the application of lip moisturiser or balm such as petroleum jelly can prevent lips becoming dry and cracked.
Just a few minutes to perform a meticulous mouth refresh for your patient (or give them the resources to do their own when able) can improve their comfort, self esteem and prognosis.
- Mouthwashes – Australian Prescriber [Internet]. [cited 2013 Oct 16]. Available from: http://www.australianprescriber.com/magazine/32/6/162/4/