Oral care and hygiene are very important for patients that are hospitalized as well as those with underlying systemic diseases that may land them in the hospital. Very few hospitals, if any, employ dental hygienists to lead the charge in this area of care, therefore it is imperative that dental professionals work with nurses to improve the quality of oral care provided to hospitalized patients. Many nurses are embarking on a mission to improve oral care for hospitalized patients. In a systematic literature review published in May 2020, in the British Journal of Nursing, the author aimed to “review the evidence for the use of available oral-care products; establish effective evidence-based oral-care practices with use of effective products; make recommendations for the future to inform oral-care guidelines.”1
At the time of this systematic review the guidelines in the authors hospital for patient oral care was as follows:
- Toothbrushing twice a day for 2 minutes with a fluoride toothpaste
- Suction toothbrushes for patients with dysphagia
- Clean dentures twice a day, remove and soak overnight
- Avoid alcohol mouthwash and oral swabs
- Patients with xerostomia, use a dry mouth toothpaste and gel
- Patients with mucositis may require mouthwash in addition to toothpaste and gel
- Nystatin is the first-line treatment for oral candidiasis
The results of the review found that there is a lack of consensus on oral-care products in a hospital setting and that selection was rarely evidence-based. Toothbrush and toothpaste were the most used products to manage oral care in the hospital. Foam swabs have been used regularly by nurses as well. Foam swabs certainly do not replace toothbrushing and the concern that they are being used in lieu of a toothbrush was an issue. Furthermore, studies indicate the texture of the swabs were not popular with patients. While a case study indicated the swab caused the death of an elderly patient when the swab became detached and was swallowed by the patient. Finally, some swabs contain lemon and glycerin which can lower the pH of the mouth contributing to tooth decalcification, xerostomia, pain, irritation and tooth decay, therefore foam swabs should be avoided.
The guidelines regarding toothbrushing and the use of fluoride toothpaste was confirmed through multiple studies that indicate this is a better option for patients than swabs, and also show a reduced risk of patients developing pneumonia. An exception for patients experiencing dysphagia should be made as these patients may require toothbrushing more frequently due to food pocketing. Tongue scraping was determined to not be beneficial to the patient, rather gently brushing the tongue was sufficient to reduce bacteria loads and reduce the risk of trauma. Mouthwash was also determined to not be beneficial to hospitalize patients as it can wash away the fluoride from the toothpaste and in some cases, depending on the mouthwash, it could contribute to xerostomia. The exception is dry mouth specific mouthwashes for those experiencing xerostomia and mucositis.
The author concludes by stating, “This literature review has explored the benefits of oral-care products for the hospitalised patient. A variety of products used for oral care have been researched, finding varying degrees of effectiveness. An overprovision of products has led to confusion as to when to use them. The minimum standard of care should consist of teeth cleaning with a toothbrush and fluoride toothpaste twice a day. The care of dentures should be considered, with denture toothpaste, denture-cleaning tablets and a sealed denture container provided for these patients. The literature reported on a variety of products used to relieve the symptom of xerostomia and mucositis. Further research into these products is required. A comprehensive oral-care guideline is needed to encourage the use of effective products, with simplicity the key to the implementation of effective oral care.”
Does your local hospital employ dental hygienists? Do you think nurses could benefit from collaborating with dental hygienists regarding patient oral care? Have you or a loved one been recently hospitalized and offered oral care?
- Woon C. Improving oral care for hospitalised patients: choosing appropriate products. Br J Nurs. 2020;29(9):520-525. doi:10.12968/bjon.2020.29.9.520