Dental Plaque accumulates rapidly in the mouths of critically ill patients and, as the amount of plaque increases, colonisation by microbial pathogens is likely. Plaque still forms in the mouths of people on nil-by-mouth, PEG-fed and oxygen therapy.
In addition, intubation and critical illness reduce oral immunity, may be associated with mechanical injury of the mouth and respiratory tract, increase the likelihood of dry mouth and the presence of the endotracheal tube also makes access for oral care more difficult.
Mouth care is an essential aspect of palliative care in all settings and should be considered part of daily routine patient care for these individuals.
Regular effective mouthcare should be planned for all patients.
This is required to ascertain the type of mouth care required and is dependent on whether a patient has natural teeth, no natural teeth, dentures or a mixture of these. It will also identify the presence of some common oral conditions that may require more targeted care.
Patients with natural teeth
Pain from these may be relieved by benzydamine 0.15% oral mouthwash or benzydamine 0.15% oromucosal spray. The mouthwash may be diluted 1:1 with water if stinging occurs. Other agents include choline salicylate or a variety of proprietary preparations for use in the mouth containing the local anaesthetic, lidocaine.
This is a condition characterised by pain and inflammation of the mucous membrane which may present as painful mouth ulceration affecting any or all intra-oral surfaces. Consider oral mucositis as a possible cause, particularly in patients receiving chemotherapy or radiotherapy. Salt water mouthwashes are effective in maintaining oral hygiene and are advised for the prevention and management of mucositis. They should be used at least four times in 24 hours to clean the mouth and remove debris.
Chlorhexidene gluconate 0.2% mouthwash can be considered to treat secondary infections or when pain limits other mouth care methods; 10ml used twice daily may be useful to inhibit plaque formation in patients unable to tolerate other mouth care measures. Dilute 1:1 with water if it stings. Alcohol-free preparations are available.
If the patient is unable to rinse and expectorate or there is an aspiration risk, soak gauze in chlorhexidine gluconate 0.2% mouthwash and gently wipe over coated surfaces, teeth and gums.
The most common types are candidiasis, denture stomatitis and angular cheilitis (soreness, redness and fissures at corners of mouth). Risk factors include wearing dentures, concomitant antibiotic or steroid use and xerostomia.
It is important to maintain oral hygiene.
Systemic treatment such as fluconazole. Topical miconazole oral gel 2% may also be used particularly for treating angular cheilitis. (For both of these, not in patients taking warfarin or statins because of risk of serious drug interaction)
In patients where this treatment is contra-indicated, or for mild oral candidiasis in non‑immunocompromised patients, nystatin oral suspension can be considered.
N.B. If a fungal infection is present, dentures must be cleaned thoroughly – soak in chlorhexidine 0.2% mouthwash (if dentures have metal components) or dilute sodium hypochlorite for 20 minutes twice a day. Toothbrushes should also be replaced.
Herpes simplex is the most common viral infection.
Learn.nes.nhs.scot. 2020. Caring for Smiles | Turas | Learn. [online] Available at: https://learn.nes.nhs.scot/3267/oral-health-improvement-for-priority-groups/caring-for-smiles [Accessed 6 April 2020].
Health Improvement Scotland. 2020. Scottish Palliative Care Guidelines. [online] Available at: https://www.palliativecareguidelines.scot.nhs.uk/ [Accessed 6 April 2020].
Hua, F., Xie, H., Worthington, H., Furness, S., Zhang, Q. and Li, C., 2016. Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia. Cochrane Database of Systematic Reviews, [online] Available at: http://Oral hygiene care for critically ill patients to prevent ventilator‐associated pneumonia.