Oral Cavity Assessment - Sage Products Inc.

ORAL CAVITYASSESSMENTand recommended Care GuideSTEP 1: ORAL ASSESSMENTbegin upon admissionDirections:• Determine rating for each category.• Add up ratings.• Implement interventions based on total score.Note: Use Universal Precautions during oral assessment andintervention. Refer to your facility policy and procedure for oral cavityexams. With all oral care, be especially cautious to prevent aspirationwith patients who have a compromised gag reflex. If assessmentdetermines a potential need for cultures, protective agents, topicalanesthetics or medications, consult a physician.CATEGORY 1 2 3 4 RATINGLipsSmooth, pink, moist,and intactSlightly wrinkled and dry;one or more isolatedreddened areasDry and somewhat swollen;may have one or two isolatedblisters; inflammatory lineof demarcationExtremely dry and edematous;entire lip inflamed; generalizedblisters or ulceration1 2 3 4Gingiva andoral mucosaSmooth, pink, moist,and intactPale and slightly dry; oneor two isolated lesions,blisters, or reddened areasDry and somewhat swollen;generalized redness; morethan two isolated lesions,blisters, or reddened areasExtremely dry and edematous;entire mucosa very red andinflamed; multiple confluent ulcers 1 2 3 4TongueSmooth, pink, moist,and intactSlightly dry; one or twoisolated reddened areas;papillae prominentparticularly at baseDry and somewhat swollen;generalized redness but tipand papillae are redder; oneor two isolated lesions orblistersExtremely dry and edematous;thick and engorged; entire tonguequite inflamed; tip very red anddemarcated with coating; multipleblisters or ulcers1 2 3 4TeethClean; no debrisMinimal debris; mostlybetween teethModerate debris clinging tohalf of visible enamelCovered with debris1 2 3 4SalivaThin, watery, plentiful Increased in amount Scanty; may be thickerthan normalThick and ropy, viscid,or mucoid 1 2 3 4See back for recommended oral care summaries.Total score:

STEP 2: ORAL CLEANSING RECOMMENDATIONSsee individual product package(s) for complete informationScore of 5NO OBSERVED DYSFUNCTION,but at possible risk for alteration in integrity, function,or comfort of oral cavity.1. Perform oral assessment on admission andonce daily.2. Remove and brush dentures 2 times daily(same time as oral care).3. Perform oral care 4 times daily (after meals,at bedtime).4. Use Ultra-Soft Toothbrush and SodiumBicarbonate Mouthpaste to clean teeth, gumsand entire oral mucosa.For patients requiring suction, use SuctionSwabs or Suction Brushes.5. Rinse with Perox-A-Mint ® Solution, AntisepticOral Rinse or water.6. Apply Mouth Moisturizer to lips and oralmucosa to lubricate and moisturizeScore of 6 to 10MILD DYSFUNCTIONof integrity, function, or comfort of oral cavity.1. Perform oral assessment on admission and 2 timesdaily (AM and PM).2. Remove and brush dentures 2 times daily (sametime as oral care); leave out if irritating.3. Perform oral care 6 to 12 times daily.4. Use Ultra-Soft Toothbrush and Sodium BicarbonateMouthpaste to clean teeth, gums and entire oralmucosa. If painful or risk of bleeding, useToothette ® Plus Swabs.For patients requiring suction, use Suction Swabs orSuction Brushes.5. Rinse with Perox-A-Mint ® Solution, Antiseptic OralRinse or water.6. Apply Mouth Moisturizer to lips and oral mucosa tolubricate and moisturize (frequently; after oral careand 4 times daily minimum).Score of 11 to 20MODERATE TO SEVERE DYSFUNCTIONof integrity, function, or comfort of oral cavity.1. Perform oral assessment on admission and3 times daily.2. Remove dentures (and leave out).3. Perform oral care 12 times daily.4. Use Toothette ® Plus Swabs and SodiumBicarbonate Mouthpaste, Perox-A-Mint ® Solutionor Antiseptic Oral Rinse to clean teeth, gums andentire oral mucosa.For patients requiring suction, use Suction Swabsor Suction Brushes.5. Rinse with Perox-A-Mint ® Solution, AntisepticOral Rinse or water.6. Apply Mouth Moisturizer to lips and oral mucosato lubricate and moisturize (every 1 to 2 hours;after oral care and as needed).Product Reorder #s Product Reorder #s Product Reorder #sAdapted with permission from Beck, S.L., Oral Exam Guide 1991. To order more cards, contact Sage Products at 800-323-222020015D © Sage Products Inc. 2009