evidence based mouth care policy - Doncaster and Bassetlaw ...

EVIDENCE BASED
MOUTH CARE POLICY
Developed & Written by: Janet Ryles – Macmillan Head and
Neck Clinical Nurse Specialist
Date: March 2007
Approved by: Clinical Review Group
Date: June 2007
Implementation Date: July 2007
For Review: November 2009
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REF: PAT/PA 17 v.1
WARNING: Always ensure that you are using the most up to date policy or procedure document. If
you are unsure, you can check that it is the most up to date version by looking on the Trust Website:
www.dbh.nhs.uk under the headings → ‘Freedom of Information’ → ‘Information Classes’ → ‘Policies
and Procedures’

CONTENTS
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REF: PAT/PA 17 v.1
Page No.
• Introduction 3
• Staff Who May Carry Out the Procedure 4
• Risk Factors 4
• Drugs / Treatments/ The Oral Cavity and Oropharynx 5
• Potential Problems / Assessment / Actions 6 - 7
• Flow chart 8
- Flow chart – Additional Information 9
- Supportive Information for Flow Chart 9
• Standard Mouth Care 10
- Patient Requiring Assistance 10
- Ulceration 10
- Coated Tongue, Teeth or Mucosa 11
- Dry Mouth 11
- Painful Mouth 11 - 13
• Information for ‘At Risk’ Groups
- Oncology and Haematology 13 - 15
- Older Patients 15
- Other Conditions 16
• References 17
• Background to Research 18
Appendix 1 - Oral Assessment Tool 19
Appendix 2 - Oral Hygiene Record Chart 20
Appendix 3 - The Oral Cavity and Oropharynx 21

• INTRODUCTION
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REF: PAT/PA 17 v.1
Quality of life issues including oral care should be a priority for staff involved in any healthcare
setting. Oral health is often affected by medical conditions and some cancer treatments. This is
often underreported, undiagnosed as problematic and inadequately treated (Adams 1996).
It is the role and responsibility of the Registered General Nurse (RGN), also Health Care Assistants
(HCA’s) and students, under supervision. The purpose of this policy is to avoid mouth care
practices which are often historical rather than research or evidence based. A mouth care
assessment tool is required in order to make an initial assessment and to promote high quality and
standardised oral care through a co-ordinated team approach. Failure to conduct an adequate oral
assessment and documentation of oral care management may be interpreted as a poor standard of
holistic care. As nurses we should be mindful of our legal responsibilities to not only ensure high
standards of care for patient/clients but also accurate documentation (NMC 2002).
Principles of evidence based practice.
There should be a local policy consisting of guidelines and an assessment tool on which to base
appropriate care needs. An agreed standard of assessing, implementing and evaluating mouth
care should be carried out every 12 hours. However, the following content is not exhaustive and
should be used to enhance the quality of care given to all our patients/clients. Staff implementing
care should be trained appropriately. Our policy and guidelines should be used in conjunction with
the Mouth Care Training pack produced by the Oral Heath Working Party 2003 (which can be
obtained from the Training and Development Department upon request) and the Royal Marsden
NHS Trust Manual of Clinical Procedures – latest version, personal hygiene section (mouth care).

• STAFF WHO MAY CARRY OUT THE PROCEDURE
The mouth care needs of patients are identified on an individual basis.
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REF: PAT/PA 17 v.1
Student nurses and midwives may deliver oral care to patients only under the supervision of a
registered nurse or midwife who are competent in this aspect of care and the supervisory role.
A registered nurse or midwife must carry out the oral assessment whilst health care assistants and
clinical support workers may carry out oral care, under supervision.
It is the responsibility of the RGN and Registered Midwife to assess, plan, implement and evaluate
care.
In line with guidelines laid down by the NMC (2002) for records and record keeping there must be a
current and appropriate plan of care for all patients. The plan must incorporate on-going evaluation
and reassessment of care and evidence that relevant interventions and observations have been
communicated to appropriate members of the multidisciplinary team.
Student nurses/midwives, health care assistants and clinical support workers should work through
the mouth care pack produced by the Oral Health Working Party (OHWP 2003). This pack is
available from the Training and Development Department upon request.
The following risk factors should be taken into account:
• RISK FACTORS
Illnesses
The literature consistently supports that various illnesses increase an individual’s risk of oral
complications.
* Diabetes * limited/restricted fluids
* thyroid dysfunction * mouth breathers
* oral disease/trauma * confusion
* cerebrovascular disease * depression
* debility * terminal illness
* acute/chronic breathing * poor nutritional status
disorders * oxygen therapy
* insufficient saliva production * a general lack of motivation or inability
to undertake oral hygiene
(Thurgood 1994, Regnard et al 1997, Holmes 1997).
• Other patients groups ‘at risk’
i) Patient receiving intensive care
ii) Patients receiving chemotherapy and patients receiving radiotherapy to the head and
neck.
iii) Patients receiving immunosuppressive therapy, i.e. transplant patients. (White 2000)
iv) Elderly patients – if ill fitting, then dentures should be avoided where possible. If well
fitting then dentures should be cleaned twelve hourly and removed at night. They
should be brushed with an unperfumed soap or toothpaste, soaked in a solution of
sodium hypocloride (Milton Sol, Denture Steradent for metal dentures) for 30 minutes
and stored dry overnight.

• DRUGS AND TREATMENTS
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REF: PAT/PA 17 v.1
There are various drugs and treatments that increase the vulnerability of the oral cavity to infection.
Drugs
Cytotoxic/Chemotherapeutic Drugs Reduce the auto-immune response
Corticosteroids Affect the healing properties of tissues
Antibiotics Alter the bacterial balance of commensal
organisms in the mouth and allow
candidal invasions
Antispasmodics Alters gut mobility and reduces salivary
Antihistamines
Anticholinergics
Psychotropics
Antidepressants and tranquillisers
production
These groups of drugs reduce salivary
production
Diuretics Potential dry mouth due to increased fluid
loss
Morphine Strong association with dryness of the
mouth
Treatments
Radiotherapy to the Head and
Neck
Reduced ability to eat/drink normally
Localised inflammation
Oxygen Therapy Unhumidified oxygen administered by
mask can dry the mouth
Intermittent suction Potential risk of damage to oral
tissues
Restricted oral intake Potential for dehydration
Anaesthesia Reduces oral secretions
• THE ORAL CAVITY AND OROPHARYNX
See Appendix 3, page 21.
Physiology
(Thurgood 1994)
The oral cavity is lined by a layer of rapidly dividing mucosal cells, which generate every 7-14 days
(Madeya 1996). These cells become a focal point for a variety of complications. Minor salivary and
sebaceous glands found beneath the epithelium surface are most important for lubrication (Madeya
1996).

• POTENTIAL PROBLEMS
Frequently cited potential oral disorders are listed below (Thurgood 1994)
Xerostomia A dry mouth
Stomatitis Inflammation and infection of the oral
mucosa
Candidiasis (oral thrush) Caused by a yeast-like fungus, Candida
albicans, which normally inhabits the
vagina and digestive system. It
commonly manifests as soft white
plaques on the mucosa and tongue.
Gingivitis Inflammation of the gums leading to
swelling and bleeding caused by plaque
attacking the damaging tissue.
Leukoplakia (white/red) A lesion that cannot be scraped off or
attributed to any other cause.
Ulceration Ulcers which are white, small, punched
out lesions of epithelial surfaces of the
mouth, probably of viral origin.
Mucositis Inflammation of the lining of the mouth
The following oral disorders are seen less commonly:-
Dental Caries Decay and crumbling of tooth structure caused by the formation of
plaque following the deposit of bacteria onto teeth, gums and
tongue.
Dysgensia Impairment of the sense of taste.
Parotitis Inflammation of the parotid salivary glands.
Periodontal
deterioration
Disease of the gums and other structures supporting the teeth.
Caused by release of toxins from plaque. These initiate a local
immunological response which attacks teeth and gums
(Thurgood 1994).
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REF: PAT/PA 17 v.1

• ASSESSMENT AND ACTION REQUIRED TO MAINTAIN ORAL HYGIENE
Equipment Required:
Torch
Toothbrush and paste
Tongue depressor
Soft paraffin ointment
Kidney dish
Suction equipment (if appropriate)
Clean procedure gloves
Tissues or wipes
Preparation:
Explain procedure to patient
Wash hands
Examine lips for any sores or cracking
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REF: PAT/PA 17 v.1
Use oral assessment tool (appendix 1) and flow chart (page 8) to assess, implement and evaluate
care. All actions and outcomes to be documented in patients care plan.

(Chlorhexidene)
START
Is the mouth healthy?
(intact mucosa, clean,
moist and pain free)
No
Is ulceration
present?
No
Are the tongue,
teeth, or mucosa
coated?
No
Is the
mouth dry?
No
Yes
Is the mouth
painful?
Flow Chart to Guide Oral Assessment and Care
Yes
Is candida
present?
Yes
Yes
Standard Mouth Care
REF: PAT/PA 17 v.1
� 12 hourly teeth brushing, if own teeth, with soft brush
and tooth paste – rinse well
� Brush dentures 12 hourly
� Brush off debris and soak dentures over night (if
required)
� Reassess every 24 hours
� Soft paraffin to lips if dry
Also if patient is unable to maintain own oral hygiene:
� If mouth dry – moisten 1-2 hourly with water soaked
mouth swabs
� Oral suction to remove excess oral secretions if
unconscious
(NB refer to special protocols if relevant)
Yes
No
Standard mouth care plus:
Difflam mouth wash every 3 hours if required for 7
days, or Adcortyl in orabase paste apply a thin layer
2-4 times daily for 5 days. refer to medical staff if
persistent longer than 5 days
Standard mouth care plus:
� Discuss with medical staff regarding antifungal
treatment
� Clean dentures at least four hourly
Standard mouth care plus
� Brush tongue/teeth with Corsodyl gel
(chlorhexidene)
� If available allow patient to suck pineapple
chunks or dissolve ¼ effervescent vitamin C
tablet on tongue
Standard mouth care plus
� Treat cause – e.g. dehydration, infection
� Consider artificial saliva
� Provide local comfort – ice cubes, pineapple
chunks, ice lollies
� Soft paraffin to lips
Consider using topical analgesics – Difflam,
Bonjela, Kamillosan Tea Tree Oil, and Gelclair
Examine for ill-fitting dentures/dental decay or
Infection. Follow local protocols for patients
undergoing chemotherapy/radiotherapy.
N.B. All medication must be prescribed
Document evaluation and care in care plan and on oral hygiene chart
Page 8 of 21

Additional Information
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REF: PAT/PA 17 v.1
NB Always give standard mouth care plus one of the following, as prescribed by the doctor:-
• Difflam (benzydamine hydrochloride) is effective in alleviating mild to moderate mucositis for
some patients. It should be used prior to meals, also consider the use of Gel Clair, an
analgesic and protective solution.
• Gelclair is useful in controlling pain due to mucositis and/or ulceration. Used as a paste and
applied one hour prior to meal times.
• Also a 2% Lignocaine solution mouthwash will help, if mucositis is more severe.
• Adcortyl in orabase is useful as pain relief for ulceration.
• Effervescent Vitamin C tablet 1000mg is valuable when treating chemotherapy induced
mucositis caused by fluorecil and provides some protection for methotrexate induced
mucositis. (Moisten tongue with water and place ¼ of a tablet directly to the tongue and
allow to fizz and dissolve)
All of these treatments should be reviewed every 5-7 days
Supportive Information for Flow Chart
The literature review in relation to mouth care focuses on the need for an initial nursing assessment
before any action is taken on necessary hygiene needs (Holmes 1993, Turner 1996, Longhurst
1998). However, the literature suggests that nurses lack a tangible knowledge base (Turner 1996,
Holmes 1993, Kite and Pearson 1995); therefore assessments are poor, and are using
inappropriate interventions. The assessment guides available have not been validated or proven
reliable which therefore limits the clinical usefulness of these tools (Turner 1996, Longhurst 1998).
For the purposes of developing a tool to be used in assessment, we as a group have chosen to
develop Eiliers et al (1998) oral assessment tool. This tool was chosen as it was easy to follow,
simple to understand, and could easily be adapted for use in various clinical settings. The tool
takes the form of a flow chart. The tool lacks sufficient detail, which is an argument supported by
Holmes (1993). However, for the purpose of setting our guidelines, we have adapted it for our
needs.
In order to be user friendly, the flow chart, by using pointers of describing the condition of the mouth
and to aid the nurse in deciding appropriate action by following the appropriate arrows returning
always to the beginning to repeat the assessment.

• STANDARD MOUTH CARE
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REF: PAT/PA 17 v.1
From the literature reviewed, the authors recognise the importance of regular oral hygiene (Turner
1995, Buglass 1995, Thurgood 1994, Kite and Pearson 1995). Buglass (1995) argues that
frequency is more important than the agents used.
Basic standard mouth care – (Literature states that the frequency of carrying out basic mouth care
is more important than the agents which are used to facilitate mouth care) Buglass EA 1995 Oral
Hygiene British Journal of Nursing 4 (a) 516-519. Guidelines for Oral Care BDA April 2000.
Guidelines for Record Keeping (2002). London Nursing and Midwifery Council.
There is however, no general agreement regarding how frequently care should be given or the tools
and agents which should be used. (Buglass 1995). For the purpose of our guidelines we have
agreed standard care entails 12 hourly tooth brushing using a soft brush and toothpaste as research
suggests the massaging effect of a soft brush stimulates mucosa promoting healthy gums. It is also
the most effective way to loosen debris and remove plaque without causing trauma providing that
care is taken (Thurgood 1994), Ransier et al 1995, Kite and Pearson 1995). Rinsing well with warm
water is important as any remaining toothpaste may have a drying effect.
Toothpaste gives a pleasant taste; always use a fluoride paste or Corsodyl gel if gingivitis is
present.
For patients with dentures the literature states all dentures should be removed overnight to prevent
shrinkage. Debris must be removed as candida may be present and be harboured in the dentures
therefore prevents introducing/ reintroducing infection. Dentures should be stored in a clean, dry
container.
Evidence suggests reassessment of the oral cavity should occur every 12 hours to ensure ongoing
care is maintained. The flowchart should be used to aid assessment.
Patient Requiring Assistance
Often patients require assistance with oral hygiene. Standard mouth care should be maintained. In
addition, water soaked swabs may be required to keep the mouth moist. Suction may also be
required to remove excess secretions. The use of soft paraffin ointment to the lips will keep them
moist and prevent them from drying and cracking. (Turner 1995).
Somerville (1999) suggests nurses, in particular intensive care nurses, are fearful of using tooth
brushes especially in intubated patients preferring to the use of sponge sticks. However, this is not
effective in the removal of plaque and debris. There is also the danger of the sponge becoming
separated from the stick. Therefore sponge sticks are not recommended.
Ulceration
If ulceration is present, but there is no candida coating the tongue teeth or mucosa, Difflam
mouthwash should be used in addition to standard mouth care. Difflam enhances oral care as it
contains a topical anaesthetic and has anti-inflammatory and anti-microbial properties (Thurgood
1994). However, it has numbing analgesic effect and must be prescribed by medical staff.

Coated Tongue, Teeth or Mucosa
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REF: PAT/PA 17 v.1
If the tongue, teeth or mucosa are coated and candida is present, anti-fungal preparations must be
used along with standard care and Difflam mouth wash. Nystatin or amphoterecin act on the
candida. These must also be prescribed by medical staff. When candida is present it may also be
harboured in the patient’s dentures. (Buglass 1989). The Trust Infection Control Team suggests
brushing dentures at least four hourly in addition to the half hour soaking in milton to reduce this
problem.
If there is no candida present carefully brushing the tongue with chlorhexidene solution and the
teeth with corsodyl gel is suggested. The acts by preventing the development and build-up of
plaque and also has an anti-microbial effect (Kite and Pearson 1995, Thurgood 1994). Pineapple
chunks contain a proteloytic enzyme, annase, which helps remove adherent coatings any may be
used to remove the coating (Regnard 1898). Vitamin C tablets work by having an effervescent
effect when placed on the tongue also aid in removing coating however there is limited research on
its effect. Care must be taken in patients receiving radiotherapy/chemotherapy.
Dry Mouth (Xerostomia) Saliva products - see below
If the patient’s mouth is dry, it is important to treat the cause. Thurgood (1994) states that artificial
saliva can be used without any detrimental effect and, is particularly useful in patients with impaired
saliva production. Thurgood (1994) and Buglass (1989) suggest ice cubes, pineapple chunks and
ice lollies may provide comfort as will using soft paraffin to moisten lips. Frequent sips of cold
water, milk or sugar free, non acidic cool drinks will help. Gel Clair provides a protective coating if
eating and drinking is painful.
Xerostomia is the prime effect of severe and rapid dental decay (Gelbart 1998). Sweeney (1998)
notes that, it can often lead to oral fungal infection. This is found in connective tissue complaints,
such as Reiter’s syndrome, as well as in menopausal women and HIV patients.
Painful Mouth
If on assessment the patient has a painful mouth it is important to determine the cause. This could
be due to ill fitting dentures, radiotherapy, chemotherapy, or infection. Topical analgesics are
effective along with standard mouth care in relieving pain. Difflam as described earlier has an antiinflammatory
effect. Bongela has a local numbing effect (Thurgood 1994)
Mucositis (inflammation of the mouth) is painful and an extremely unpleasant side effect of some
cancer treatments. It has an acute phase usually due to chemotherapy or radiotherapy to the oral
cavity. Normal tooth brushing should continue using a soft toothbrush if possible; alternatively
chlorhexidene mouth wash can be used. It should be used 3-4 times daily. It helps with plaque
control although its value in reducing symptoms of mucositis is less clear. Very few therapies have
been used in randomised prospective trials. Recent evidence suggests that the use of an antibiotic
lozenge may reduce the most severe symptoms of mucositis. Experimental evidence supports the
use of Gel Clair in the first instance
In normal saliva production we produce 1-2mls per minute. 80% is from the Parotid Gland. Saliva is
anti-bacterial and anti-fungal and helps maintain oral PH for food digestion.

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REF: PAT/PA 17 v.1
Parotid function can be partially maintained by radiotherapy delivery that spares the contralateral
gland. The symptoms of Xerostomia can be helped by:
i) Frequent sips of cold water/milk or other sugar free non acidic cool drinks
ii) Saliva substitutes:
Saliva Orthana ) both contain flouride and are
) appropriate saliva
) substitutes for dentate
) people
* Oral Balance Mouthwash
Glandosane mouthwash
Salivix Pastilles ) for edentate patients only. These
) are acidic and consequently will
) rapidly erode natural teeth and
) cause tooth sensitivity.
* For these materials to be effective Oral Balance dentifrice must be
substituted for conventional toothpaste. The sodium lauryl
succinate in toothpaste destroys the bulking agent within the Oral
Balance saliva replacement gel.
iii) Flavourless salad oil or dietary fat at night time lubricates the lips and tongue
iv) Sugar free chewing gum stimulates saliva production (e.g. Orbit).
v) Salivary stimulants can cause unwanted side effects that are often more distressing than
the Xerostomia. The following have been used:
Pilocarpoine – ophthalmic drops – 5-10mgs. 3 times daily.
Whilst this stimulates salivary secretion it cannot resurrect a damaged gland i.e. parotids
in radiotherapy for head and neck cancer patients.
Anatholetrithione ( Sialor-sulfarlem, latema) 1-2 tablets can be used 3 times daily.
Pilocarpine and Anetholetrithione can be combined
vi) Ripe bananas are a good lubricant; however, they should be avoided for dentate patients
because of their high refined sugar content.
• When mouth is too painful for cleaning and mouthwash cannot be used, the oral
tissues should be swabbed with Polygon oral swabs (Rochaille Medical Ltd
Cambridge UK) or gauze.soaked in chlorhexidene 3 – 4 times daily. (Fitton 1989)
• Hydration and nutrition are frequently reported as important factors in oral hygiene
(Thurgood 1994). Reduced oral intake has the effect of reducing the production of
saliva thus the cleansing effect of saliva on the tongue and the mucous membrane is
lost. Much of the literature notes that a factor in the control of bacterial growth is the
production of saliva. Saliva contains several anti-bacterial factors which suppress
bacterial and fungal colonisation. Also, the mechanical action of mastication
promotes the washing action of saliva, and helps prevent the firm attachment of
micro organisms to the surfaces (Somerville 1999).

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REF: PAT/PA 17 v.1
• Gilbart (1998) cites certain systemic illnesses that are associated with Aphthous
ulcers. These include Crohn’s disease, sarcoidosis and coelic disease. Sweeney
(1998) adds other various factors that contribute to ulceration. For example,
haematological and other deficiency states, (iron or vitamin B12 deficiency,
anaemia), endocrine problems, stress, allergy, autoimmune diseases and HIV.
• Oral thrush is commonly found in diabetes, as a side effect of antibiotic or radiation
treatment, and as a result of insufficient saliva. Candida is also associated with HIV.
• Inflammation of the gingival (gingivitis), often with minor bleeding, is caused by poor
hygiene and consequently a build up of plaque (Gelbart 1998). It is the first stage of
periodontitis. Due to the highly vascular nature of the mucosal tissue in the gums,
tissue destruction can lead to the formation of a communication channel between the
bacteria in the plaque and the bloodstream (Somerville 1999). Additionally,
inflammation of this area can lead to tissue and bone destruction and then to tooth
loss (Kite and Pearson 1995).
• Patients with oral cancers tend to be elderly, wear dentures and seldom visit their
dentists (Gelbart 1998). Combined high intake of tobacco and alcohol are particular
risk factors. Health education and health promotion is paramount to reduce this risk
and improve oral health.
INFORMATION FOR ‘AT RISK’ GROUPS
Oncology and Haematology
Much of the literature surrounding oral care in oncology is United States based and involves small
samples. It is therefore worthy of caution when generalising to the population as a whole.
Incidence
Both radiotherapy and chemotherapy can cause specific oral problems. The oral mucosal cells are
extremely vulnerable to the effects of antineoplastic therapy. Oral complications increase in severity
if the patient is receiving concurrent radiotherapy and chemotherapy.
The incidence of oral complications in adults undergoing chemotherapy for solid tumours ranged
between 12 – 40% (Niedwig et al 1992, Graham et at 1993). However Holmes (1997) states that
48% to 75% of patients receiving 5Fu report Stomatitis. Dodd (1996) agrees that the figure for 5Fu
induced Stomatitis is 75%.
Patients undergoing radiotherapy to the Head and Neck routinely have oral complications. (Ganley
1996).
These figures indicate the extent of the problem in this group of patients.
Patho-Physiology
Visible signs of inflammation and oral ulceration can be observed 7-14 days following
chemotherapy/radiotherapy (Madaya, 196a), although Graham et al (1993) report effects as early
as 3 days into treatment.

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REF: PAT/PA 17 v.1
Pain caused by Stomatitis initially presents as a burning sensation (Graham et al 1993). This
progresses to a general sensitivity to hot and cold (Nieweg et al, 1992). In severe cases there may
be infection present.
Chemotherapy
Cytotoxic drugs inhibit cellular replication. Thus the production of new cells is insufficient to
maintain mucosal integrity. Stomatitis may result from damage o the mucous membranes of the
mouth and is largely unpreventable.
Problems occur either due to direct effects of chemotherapy or indirect effects of myelosuppression
or immunosuppression when neutropenia renders the patient vulnerable to infection. Therefore any
drug causing myelosuppression may indirectly cause Stomatitis.
Thinning and ulceration of the mucus membrane occurs within four to seven days of the
commencement of chemotherapy. Fluid and food intake are also reduced, due to nausea, vomiting
and general malaise. This compounds the problem as debris and plaque accumulate in the mouth
(Turner 1996). Thus the mucus membrane is ineffective to invasive infections and there is an
increased risk of gingivitis and dental caries. The nausea and vomiting may also result in
malnutrition and therefore poor tissue healing and repair. However, Stomatitis tends to be self
limiting and resolves once treatment has completed. Indirect effects occur within 12-16 days usually
coinciding with the nadir period when patients are neutropenic. The mucosa, which is already
compromised, becomes more susceptible to bleeding and infection. Healing occurs as the
neutorphil count returns to normal (Holmes 1997).
Most oral infections amongst chemotherapy patients originate from their own microflora, with the
oral cavity acting as the primary source in the development of septicaemia in immunosuppressed
patients. (Eilers et al 1988, Holmes 1997). By reducing the number of microbes in the oral cavity
patients may be able to reduce their risk of acquiring a systemic infection (Ransier et at 1995).
Patients with impaired renal and/or hepatic function are at an increased risk of oral complications
due to the reduced metabolism and/or excretion of antineoplastic drugs (Holmes 1997). This is
thought to be because persistent blood or tissue levels of cytotoxic agents delay re-epitheliaisation.
Effects on the Oral Cavity Associated With Chemotherapy (Holmes 1997)
Generalised effects
• Xerostomia
• Altered taste perception
Inflammatory changes
• Mucositis
• Ulceration
Infectious Complications
• Periodontal infection/disease
• Dental caries
• Viral infections (e.g. herpes simplex)
• Fungal infections (e.g. candida albicans)

Indirect effects of secondary to myelosuppression
• Gingival bleeding
• Atrophy of tongue and buccal mucosa
Radiotherapy
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REF: PAT/PA 17 v.1
Radiotherapy to the head and neck can also cause localised problems. The oral mucosa is very
sensitive to the radiation because of its short cell life. This reduction in cell renewal results in
mucosal atrophy and ulceration. Hypertrophy of the salivary glands follows radiotherapy treatment
and reduces the salivary flow, causing Xerostomia and dysphagia (Turner 1996). Xerostomia (dry
mouth due to failure of salivary secretion) is the most frequently reported side effect associated with
radiotherapy to the Head and Neck. It may be permanent or temporary. The protective cleansing of
the mucus membranes and teeth is lost, as is the acidic protective barrier against bacteria.
Oral complications can also affect the taste buds and the ability to swallow, therefore impinging on
fluid and nutritional intake (Graham et al 1993, Dudjak 1987).
Additionally, radiotherapy to the head and neck can affect the structures can occur of the mouth,
including oral musculature, alveolar bone and developing teeth. Damage to teeth up to three years
following treatment (Gelbart 1998).
Older Patients
The aging process, even when uncomplicated by illness, produces a multitude of changes in the
structure and function of the body which may combine to make maintenance of oral health difficult.
Age related changes to oral cavity
• Gingiva may recede, causing teeth to loosen, and forming pockets for food to sit it, which will
increase the risk of caries.
• The root pulp of the tooth fibroses and the teeth become more brittle, increasing the risk of
fractures, particularly in the base of the tooth.
• Mucosal atrophy and thinning results in a higher likelihood of traumatic damage and
ulceration.
• Changes in the shape of the bony ridges may result in ill fitting dentures, which themselves
may be the cause of traumatic damage.
• Saliva production decreases with age, sometimes dropping to 1/3 of original adult
production; so the patient may suffer from Xerostomia. As saliva also plays a part in
controlling bacteria and fungal growth within the oral cavity, the patient will also be more
prone to Candidiasis.
• The tongue atrophies causing reduction in taste sensation (Dysgensia).
• Swallowing time slows; food may not be effectively cleared from the mouth which will
enhance the development of plaque.
Other age related physiological changes which may relate to the maintenance of a healthy oral
cavity
.
• Decreased response to painful stimuli and an increasing tolerance to pain may
increase the risk of insult to the oral cavity.
• Muscle tremors associated with degeneration of the extrapyrimidal system; and
deterioration of cartilage surface at joints; and the formation of bone spurs may all
limit patients functional ability to self care for their mouth and teeth.

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REF: PAT/PA 17 v.1
• A reduction in the amount of intracellular fluid causes an increased risk of
dehydration leading to thickened saliva, or dry mouth.
• Cognitive motivation for learning lessens; attention span may be reduced; both of
which may reduce patients’ ability to care effectively for their mouth and teeth.
Elipoulous (1997) suggests “an understanding of common ageing changes is essential to ensure
competent gerontological nursing practices”
In addition to these physiological processes, a number of abnormal conditions, which may present
at any time but are common in the elderly patient, may occur, and these should be considered in
combination with the normal changes of ageing. The following list is not comprehensive but
provides some examples.
Other conditions:
• Cerebrovascular accident: depending on the area of the brain affected, may affect
swallowing, speech, general functional ability; cognitive ability, all of which, as already
discussed, have a bearing on the condition of the oral cavity.
• Dementia: may cause reduced functional ability; patients may also experience a reduced
appetite, and are at risk of becoming dehydrated.
• Parkinson’s disease: Reduced function and some associated dementia may occur.
• Depression: can cause loss of appetite, reduced motivation to self care and to take oral
fluids.
• Drug therapy: as a response to abnormal conditions. Xerostomia is a side effect of a
number of drugs, including anxiolytics, antidepressants, antipsychotics, (particularly
anticholinergic drugs), diuretics (due to fluid/electrolyte intolerance). Antibiotics to treat
infection may results in oral thrush. See Drugs and Treatments table, page 5.

REFERENCES
Page 17 of 21
REF: PAT/PA 17 v.1
• Buglass E A (1995) Oral Hygiene, British Journal of Nursing, 4(9): 516-519
• Dodd, M et al (1996) Randomised Clinical Trial of Chlorhexadine Versus Placebo for
Prevention of Oral Mucositis in Patients Receiving Chemotherapy. Oncology Nursing Forum,
23(6): 921-927
• Dudjak (1994) Mouth care for mucositis due to radiation therapy. Cancer Nursing, 10(3):
131-140.
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• BACKGROUND TO RESEARCH
Key Words
Page 18 of 21
REF: PAT/PA 17 v.1
“CANCER, ORAL CARE, ORAL ASSESSMENT, ORAL ASSESSMENT TOOL, ORAL HYGENE
AND MOUTH CARE WERE USED”
Literature Review
The literature review in relation to mouth care focuses on the need for an initial nursing assessment.
(Holmes 1993, Turner 1996, Lomghurst 1998) It also highlights that there is a lack of a tangible
knowledge base in this field. (Turner 1996, Holmes 1993, Kite and Pearson 1995). However authors
recognise the importance of regular oral hygiene. Buglass (1995) argues that frequency is far more
important than the agents used. However there is no general agreement regarding frequency of
care, agents to be used or recommended assessment tool.
For the purpose of this paper it was intended to adapt an approved assessment tool (RCS and
BDSH 2001) to enhance mouth care practice. Whilst it is agreed that the assessment tool may be
useful as a research outcome measure it is open to criticism in that it produces a score rather than a
diagnosis. However if used with a flow guide to oral assessment and care it is thought that this will
highlight any problems, standardise care and give advice on treatments.

ORAL ASSESSMENT TOOL
Page 19 of 21
REF: PAT/PA 17 v.1
Appendix 1
Please insert appropriate number in relevant box based on your clinical examination of the patient.
Contact the Medical Team for further advice on the management of patients with scores of 3.
PATIENT NAME: ____________________________ PLEASE DATE AND SIGN
METHOD OF
1 2 3 4 5 6 7
ASSESSMENT
ASSESSMENT DATE:
VOICE
3 = difficult/painful speech
2 = deeper/raspy
1 = normal
SWALLOW
Converse with the patient.
3 = unable to swallow
2 = painful
1 = normal
LIPS AND ANGLE OF MOUTH
Ask patient to swallow.
3 = ulcerated/with or without bleeding Observe and palpate the
2 = dry/cracked
1 = normal
TONGUE
tissues
3 = blistered/cracked
Observe the appearance of the
2 = coated or loss of papillae
1 = smooth, pink, moist
SALIVA
tissues
3 = Absent
Insert tongue depresser and
2 = thick/ropy
observe tongue and floor of
1 = watery
MUCOUS MEMBRANES/GINGIVA
mouth
3 = Ulceration/bleeding – gentle pressure Observe the appearance of the
2 = candidal infection suspected –
reddened/coated or white patches
1 = pink and moist
ORAL CLEANSING COMPLIANCE
tissues
3 = unable to clean
Observe tooth brushing/denture
2 = cleans but needs help
1 = no difficulties - self care
cleaning
(Adapted from Eilers, J, Berger, A, Peterson, M. Development, testing and application of the Oral Assessment Guide. Ongology Nursing Forum 15 (3): pp 325-330a: 1988) Copyright Host
Defence Unit Great Ormond Street Hospital Trust.

NAME:
UNIT NUMBER:
(Use with Oral assessment tool)
DATE/
TIME
Doncaster and Bassetlaw Hospitals NHS Foundation Trust
SCORE
ORAL HYGIENE RECORD CHART
ACTION TAKEN
INCLUDING PRODUCT
USED
Page 20 of 21
REF: PAT/PA 17 v.1
EVALUATION
Appendix 2

The Oral Cavity and Oropharynx
Page 21 of 21
REF: PAT/PA 17 v.1
Appendix 3