Working in partnership

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Lincolnshire guidelines for the assessment and provision of Mouth Care (Adult Palliative Care) Reference No: G_CS_82 Version: 4 Ratified by: Lincolnshire Community Health Services NHS Trust Board Date ratified: 11 May 2022 Name of originator / author: Kathryn O’Brien Macmillan Palliative Care CNS ULHT, Michelle Dale Macmillan Palliative Care CNS LCHS, Abi Alexander Macmillan Palliative Care CNS LCHS. Anna Chippendale Macmillan Palliative Care ULHT Name of responsible committee: Clinical Safety and Effectiveness Group Date approved by responsible committee: 6 April 2022 Date issued: May 2022 Review date: March 2024 Target audience: Trust staff Distributed via: LCHS website

Lincolnshire Community Health Services St Barnabas Hospice Marie Curie ULHT Lincolnshire LMC

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Version Control Sheet

Version Section / Para / Appendix

Version / Description of Amendments

Date Author / Amended by

1 New Document January 2017 Kim Barr, Michelle Dale

2

Reference Updates. Addition of Denture sunflower Addition of Best Practice Guidance from Oral Health Alliance Group

June 2019 Kathryn Obrien, Macmillan Palliative CNS ULHT. Michelle Dale, Macmillan Palliative CNS LCHS. Abi Alexander, Macmillan Palliative Care Nurse LCHS.

3

Front page Whole Document Whole document Appendix 4 Appendix 6

Addition of EPACCS and GSF stage use. Change of title from policy to guideline and removal of the word wide Condensed to reflect current guidelines and practice. References updated ULHT oral hygiene chart updated New Appendix added to reflect national guidelines on mouthcare in COVID patients.

April 2021

Abi Alexander, Michelle Dale Isabella Dollman Dr Clive Cole (GP) Sarah Mumby (Marie Curie) Sam Lewis (ULHT)

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4

Whole documented Page 5

Policy transferred to new LCHS template Training statement amended to state if basic mouthcare cannot be given by health professional, to contact line manager first and then if further support required to speak to specialist palliative care team.

March 2022

Abi Alexander, Kay Howard, Jackie Rizan.

Copyright © 2022 Lincolnshire Community Health Services NHS Trust, All Rights Reserved. Not to be reproduced in whole or in part without the permission of the copyright owner.

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Contents Version Control Sheet ................................................................................................ 2

Procedural Document Statement ............................................................................... 6

Background Statement ........................................................................................... 6

Key words ............................................................................................................... 6

Responsibilities ....................................................................................................... 6

Training ................................................................................................................... 6

Dissemination ......................................................................................................... 6

Resource implication .............................................................................................. 6

Consultation ............................................................................................................ 6

Monitoring ............................................................................................................... 6

Equality Statement .................................................................................................. 6

Introduction ................................................................................................................ 7

Purpose ...................................................................................................................... 7

Definitions .................................................................................................................. 7

1. Introduction ......................................................................................................... 8

2. Assessment ........................................................................................................ 8

3. Common oral problems. (Marie Curie 2021) ....................................................... 8

3.1 Dry Mouth...................................................................................................... 9

3.2 Painful Mouth .............................................................................................. 10

3.3 Management of oral infections .................................................................... 11

3.3.1 Fungal infections .................................................................................. 11

3.3.2 Viral infections .......................................................................................... 12

3.3.3 Bacterial infection ..................................................................................... 12

3.3.4 Halitosis.................................................................................................... 12

3.4 Sialorrhoea (excessive drooling)..................................................................... 13

3.5 Alteration in taste ............................................................................................ 13

4. Mouthcare in last days of life ................................................................................ 14

References ............................................................................................................... 15

Appendix 1: Procedure Guidelines ........................................................................... 16

Equipment for standard mouth care...................................................................... 16

Procedure for delivering mouth care ..................................................................... 16

Appendix 2: Oral Care self-care – Advice for carers ................................................ 19

Appendix 3: Moutheze information leaflet ................................................................ 20

Appendix 4: Oral Assessment Tool .......................................................................... 21

Appendix 5: The Denture Sunflower......................................................................... 23

Appendix 6: Mouthcare COVID-19 Guidance ........................................................... 24

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Mouth care for non-ventilated patients (adults and children) ................................ 24

Mouth care for ventilated hospital patients - under the direction of the nurse in charge ................................................................................................................... 25

End of life care ...................................................................................................... 25

Review of document ................................................................................................. 26

Appendix 7 Equality and Health Inequality Impact Assessment Tool ....................... 27

Service or Workforce Activity Details .................................................................... 27

Equality Impact Assessment ................................................................................. 27

Risks and Mitigations ............................................................................................ 28

Decision/Accountable Persons ............................................................................. 29

Purpose of the Equality and Health Inequality Assessment tool ........................... 29

Checklist ............................................................................................................... 29

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Procedural Document Statement Background Statement The purpose of this guidance is to ensure a consistent

approach to the Mouth care of adult palliative care patients in Lincolnshire

This guidance has been developed across services and will be implemented within the organisations who have ratified this policy.

Key words Mouth care, oral care, palliative care, adult Responsibilities All staff are required to ensure that the guidelines are

adhered to within the organisations who have ratified these guidelines.

Training Within LCHS, if a healthcare professional cannot give

basic mouthcare, then please highlight to their line manager. If further training is required, contact the specialist palliative care team or further support.

Dissemination Via LCHS Team Brief and intranet. Also available on

www.eolc.co.uk Resource implication Access to recommended oral care products and

prescribed medications Consultation Not required Monitoring Monitored by clinical leaders Equality Statement As part of our on-going commitment to promoting

equality, valuing diversity and protecting human rights, Lincolnshire Community Health Services NHS Trust is committed to eliminating discrimination against any individual (individual means employees, patients, services users and carers) on the grounds of gender, gender reassignment, disability, age, race, ethnicity, sexual orientation, socio-economic status, language, religion or beliefs, marriage or civil partnerships, pregnancy and maternity, appearance, nationality or culture.

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Introduction This document relates specifically to mouthcare in palliative and end of life patients. The document has been written to provide health care professionals working in community and hospice settings with a safe framework to follow. This guidance will facilitate effective mouth care. This will be delivered within a safe and supportive environment.

Purpose The purpose of this guidance is to ensure a consistent approach to the Mouth care of adult palliative care patients in Lincolnshire. The aim is to create a united approach to mouth care to ensure all patients are receiving evidence-based mouth care

Definitions • Mouth care (Oral Hygiene) – the condition or practice of maintaining the

tissues and structures of the mouth in a healthy state.

• Aspiration – food or fluid go below the level of the vocal cords which can lead to chest infections and aspiration pneumonia.

• Cheilitis – reddened, crusting or bleeding area, often around the corner of the mouth

• Debris – dead, diseased or damaged tissue and any foreign material that is to be removed from a wound or other area being treated.

• Dental caries – a plaque-induced disease caused by the complex interaction of food, especially starches and sugars, with bacteria that form dental plaque.

• Dental plaque – a biofilm composed of microorganisms that attaches to the teeth and causes dental caries and infections of the gingival tissue.

• Dysphagia – difficulties with eating, drinking and swallowing

• Halitosis – offensive breath commonly caused by poor oral hygiene, dental or oral infections.

• Mucositis – inflammation of the lining of the mouth

• Oral candidiasis – also known as oral thrush, this common fungus can become prevalent when the natural fauna and flora of the body are unbalanced.

• Sialorrhea- Excessive drooling

• Stomatitis – inflammation of the oral cavity with or without ulceration.

• Ulceration – ulcers which are white, small, punched out lesions of epithelial surfaces of the mouth.

• Xerostomia - dryness of the mouth caused by reduced saliva secretion

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1. Introduction Mouth care is an essential aspect of palliative care in all settings and should be considered part of daily routine care. Assessment and intervention should be instigated early to optimise patient comfort and prevent more serious problems and treatment complications (Scottish palliative Care Guidelines 2020).

Key principles

• Undertake regular effective mouth care for all patients.

• Monitor response to interventions.

• Identify serious oral problems that require referral, for example to palliative care

specialist or a dentist.

2. Assessment

• Patients who are receiving or have recently received chemotherapy or

radiotherapy need careful monitoring both pre- and post-treatment.

• Medication history is important as numerous medications can affect the oral

environment:

o opioids, diuretics and anticholinergics increase dry mouth

o steroids increase the risk of candidiasis

o bisphosphonates increase the risk of osteonecrosis of the jaw. Ill-fitting

dentures and surgical intervention including tooth extraction increase this risk,

highlighting the need for preventative oral hygiene therapy.

• For patients at the end of life, ensure that active routine assessment is carried out.

• Ensure comfort and minimise pain when carrying out an assessment by lubricating

cracked lips with a water-based product.

• Petroleum lip balms should be avoided due to flammability and aspiration risk.

• Previous applications of water-based lubricants should be gently removed before

replacing.

• Remove dentures before examining the mouth or performing routine mouth care.

• Check the lining of the mouth is clean.

• Look for signs of dryness, coating, ulceration, infection or tooth decay. Assess for

pain.

• Consider dental referral with the patient’s consent for persistent oral symptoms or

if it has been more than one year since the patient has been examined by a dentist.

3. Common oral problems. (Marie Curie 2021)

Common mouth problems in palliative care include:

• dry mouth • painful mouth • infections

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• bad breath (halitosis) • changes in taste • drooling

3.1 Dry Mouth

Towards the end of life, people often become less interested in eating and drinking. If the patient’s mouth becomes dry, you can moisten it to keep them comfortable.

If the patient is conscious, moisten their mouth regularly with water from a spray or dropper, or by placing ice chips in their mouth. If the patient is unconscious, use a spray or dropper every hour. (Marie Curie 2021) In the community this can be done by the patient’s family members as well as healthcare professionals.

• Oral care should be offered at least four times daily or as tolerated. Some patients

may need more frequent care.

• Where possible, identify and manage the underlying cause, for example review

medication, manage anxiety, treat infection, humidify oxygen and if appropriate

encourage hydration.

• Gently remove coatings, debris and plaque from soft tissues, lips and mucosa.

• Failing to gently remove dried secretions, debris and plaque gently can cause pain,

ulceration, bleeding and predispose to infection.

• Use a small headed toothbrush with soft bristles or a product with a fixed cleaning

head such as “MoutheZe”.

• Encourage hydration. Cold, unsweetened drinks (such as sips of water) should be

taken frequently throughout the day if possible. Sucking crushed ice or frozen tonic

water may provide relief.

• Check the patient has no allergies to medications likely to be used before starting.

• Saline mouthwashes may help to clean the mouth. Patients in hospital may use

0.9% sodium chloride from a vial to be followed by rinsing with cold or warm water.

For patients at home, 1 teaspoon of salt may be added to a pint of cold or warm

water. A fresh supply should be made daily.

• Saline nebulisers may help with thick or crusty secretions.

• Saliva stimulation (for example sugar-free chewing gum, sugar-free boiled sweets,

pastilles, mints) should be considered if the patient is able to comply.

• Saliva substitutes (for example oral gel, spray or mouth rinse) may be used if other

measures are insufficient. Refer to The British National Formulary (BNF). Enough

artificial saliva should be used to cover the whole mouth. Applying the artificial

saliva under the tongue can help to spread the artificial saliva around the whole

mouth.

• There is no strong evidence that topical therapy is effective for relieving xerostomia

but many patients find them useful.

• The ideal product should be acceptable to the patient, be of neutral pH and contain

electrolytes (including fluoride) to correspond approximately to the composition of

saliva.

• Some preparations for dry mouth are derived from animal products and may be

unsuitable for vegetarians and people from certain religious groups.

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• Some preparations with an acidic pH (for example Glandosane®) should be

avoided in dentate patients as long term use of an acidic product may demineralise

tooth enamel.

• Attention should also be paid to the lips. Applying a water-based product will help

to prevent or treat cracked lips.

• A dry mouth can contribute to tooth decay. Where appropriate, patients should be

encouraged to attend their dentist regularly for assessment and necessary

treatment.

(Scottish palliative care guidelines 2020, Macmillan 2020)

3.2 Painful Mouth

• Causes of mouth pain include trauma (from sharp teeth), haematinic deficiency,

viral infection (herpes simplex), aphthous ulceration, oral malignancy and

mucositis.

• Oral pain may be relieved by benzydamine 0.15% (for example difflam) 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 (Bonjela®) or a variety of proprietary

preparations for use in the mouth containing the local anaesthetic,

lidocaine. Lidocaine spray (10%) may be used but may increase the risk of

choking if used before meals due to anaesthesia of the pharynx.

• Consider oral mucositis as a possible cause, particularly in patients receiving

chemotherapy or radiotherapy. Oral mucositis 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.

• Soluble paracetamol and/or aspirin used as a mouthwash provides no topical

effect. Do not advise patients to use this as a mouthwash.

• Corticosteroids are not advised for the management of oral mucositis.

• Saltwater 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.

• Patients in hospital may use 0.9% sodium chloride from a vial to be followed by

rinsing with cold or warm water. For patients at home, 1 teaspoon of salt may be

added to a pint of cold or warm water. A fresh supply should be made daily.

• Gelclair® is a viscous gel specially formulated to aid in the management of lesions

of the oral mucosa. It forms a protective film that, by coating and sticking to the

lining of the mouth and throat, offers rapid and effective pain management. The

contents of one sachet should be diluted with 40ml of water and used as a

mouthwash. Repeat three times a day, 1 hour before eating or drinking. Please

note product is restricted on Lincolnshire formulary to oncology patients.

• Carmellose paste (Orabase®) is a mucoadhesive paste that will adhere to lesions

forming a protective barrier.

• Coating agents will not relieve persistent inflammatory pain but may reduce contact

pain, for example from eating or drinking. The coating/barrier may prevent

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penetration of orally applied medicines, for example nystatin, which will need to be

given prior to applying the coating agent.

• Chlorhexidine 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. Please note MHRA alert of anaphylaxis risk in respect to chlorhexidine.

• 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.

• Consider referral to a palliative care specialist or dentist with consent if there is

refractory oral pain or severe mucositis.

(Scottish palliative care Guidelines 2020, NICE guidance 2018)

3.3 Management of oral infections

3.3.1 Fungal infections

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.

• Maintain oral hygiene.

• Systemic treatments are likely to be more effective than topical treatments. In many

cases, a systemic antifungal such as fluconazole (capsules or suspension) 50mg

daily for 7 days will be indicated with review and extension as necessary. Higher

doses may be necessary in immunocompromised patients. Doses may need to be

reduced in renal impairment. Topical miconazole oral gel 2% may also be used.

Apply 2.5ml topically four times daily, retained near lesions before swallowing.

Continue use for at least a week after lesions have healed. Topical miconazole

should be considered for treating angular cheilitis.

• In patients where this treatment is contra-indicated, or for mild oral candidiasis in

non-immunocompromised patients, nystatin oral suspension 100,000 units/ml can

be considered. Prescribe 1ml four times daily after food, usually for 7 days. Rinse

around mouth and hold in contact with affected areas as long as possible. Continue

use for 48 hours after lesions have healed. Some patients may be unable to comply

with the administration instructions for nystatin and require a systemic antifungal.

• Always check the BNF or seek advice from a pharmacist before prescription of

antifungal medication as there is a risk of serious drug interactions. Fluconazole

and miconazole (including topical route) should be avoided in patients prescribed

warfarin and statins.

• Swab angles, tongue and nostrils to investigate possible Staphylococcal infection.

If present, adjust treatment accordingly.

o If a fungal infection is present, dentures must be cleaned thoroughly – soak in

chlorhexidine 0.2% mouthwash (if dentures have metal components).

Toothbrushes should also be replaced.

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o If symptoms persist, consider referral to a dentist with consent or a palliative

care specialist.

3.3.2 Viral infections

Herpes simplex is the most common viral infection.

• Treat infections inside the mouth with oral aciclovir: 200mg five times a day for at

least 5 days (or until healing is complete). Soluble preparations are available.

• The dose of aciclovir may be doubled or intravenous treatment considered if the

patient is immunocompromised or if absorption is impaired. In this case seek

advice. Doses may need to be reduced in renal impairment.

• The use of antimicrobial mouthwashes (either chlorhexidine 0.2% mouthwash or

hydrogen peroxide mouthwash, 3%) controls plaque accumulation if toothbrushing

is painful and also helps to control secondary infection in general.

• Immunocompetent patients in the early stages of an uncomplicated herpes simplex

infection in the lips (cold sore) should receive a topical antiviral preparation, for

example acyclovir 5% cream applied 5 times a day for 5 days.

• Provide supportive therapy: encourage fluid intake, keep mouth moist, apply water-

based lubricant, antipyretic medication and analgesia.

• Viral infections are highly contagious. Strict adherence to infection control

measures is essential.

3.3.3 Bacterial infection

• The mouth may become infected and malodorous particularly if there is an oral

cancer infected with anaerobic organisms. Poor dental hygiene may also

encourage infection. Oral metronidazole (400mg every 8 hours for 3 to 7 days or

longer if necessary) is recommended to control anaerobic infection and the

associated odour.

3.3.4 Halitosis

• Regular oral hygiene, fluid intake and modification of diet should be encouraged

where possible.

• Regular use of a gargle or mouthwash containing an antimicrobial agent (for

example chlorhexidine) may reduce breath odour.

• Consider artificial saliva if the mouth is very dry.

• Treat any underlying cause.

(Scottish Palliative Care Guidelines 2020, NICE 2018)

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3.4 Sialorrhoea (excessive drooling)

• Excessive drooling of saliva is common in neurodegenerative disorders such as

motor neurone disease (MND), Parkinson’s disease and multiple sclerosis. The

cause is usually impaired swallowing of saliva rather than excessive saliva

production.

• Advice should be given on posture, diet and oral care.

• For bed-bound patients, consider regular positional changes by carers/nursing

staff with advice from a physiotherapist where necessary.

• Referral with consent to a speech and language therapist should be considered for

advice on swallowing techniques.

• Consider a trial of an antimuscarinic agent for treatment for sialorrhoea:

o hyoscine hydrobromide 1mg/72 hour transdermal patch. If necessary, use 2

patches concurrently. Oral dose (tablets) 300micrograms up to three times

daily.

o amitripyline 10mg to 25mg at night. Please note this would be used off label.

o atropine 1% eye drops may also be used, 4 drops on the tongue or sublingually,

every 4 hours as required.

• For subcutaneous administration, hysocine (as hysocine butylbromide) are

preferred because of the lower incidence of central nervous system effects.

• Medication to manage sialorrhoea may exacerbate dry mouth causing thickened

secretions which may be more difficult to clear.

• Where there is thick, tenacious saliva:

o review all current medicines, especially any treatment for sialorrhoea

o consider treatment with humidification, sodium chloride 0.9% nebulisers

and carbocisteine

• If treatment for sialorrhoea is not effective or not tolerated, consider referral to a

palliative care specialist or the specialist team looking after the patient.

(Scottish Palliative Care Guideline 2020, NICE 2018)

3.5 Alteration in taste

• Stress the importance of good oral hygiene

• Treat dry mouth

• Treat oral candidiasis

• Refer to a dietician where appropriate. Give general advice whilst waiting for

appointment ie:

o Encourage tart foods such as lemon, pickles etc if no ulcers or

stomatitis present

o Recommend food that leaves its own taste ie fresh fruit

o Add or reduce sugar as appropriate

o Eat food with strong seasoning

o Drink more fluids

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4. Mouthcare in last days of life

• Carry out mouth care as often as necessary to maintain a clean mouth.

• In people who are conscious, the mouth can be moistened every 30 minutes with water from a water spray or dropper, or ice chips can be placed in the mouth.

• In unconscious people, moisten the mouth at least once an hour with water from a water spray, dropper, or moutheze oral care stick.

• To prevent cracking of the lips, smear petroleum jelly (for example Vaseline®) on the lips. However, if a person is on oxygen apply a water-soluble lubricant (for example K-Y Jelly®).

• When the weather is dry and hot, if possible, use a room humidifier or air conditioning.

• Manage pain symptomatically, using analgesics via a suitable route. Stop treatment of the underlying cause of pain when the burden of treatment outweighs the benefits.

• Dry mouth and thirst are very common in people who are dying, regardless of whether they are dehydrated. Reversing dehydration improves symptoms in only a small number of people.

The basis for these recommendations is expert opinion:-

• People in the last 24–48 hours of life often have difficulty taking food, fluid, or oral medication. Good symptom control may allow the dying person to eat, drink, and talk comfortably. Mouth care can easily be carried out by the family, giving them greater involvement in the care of their dying relative.

(NICE Palliative Care–Oral 2018,

NICE Guidance on care of the dying adult in the last days of life 2015)

Working in partnership

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References Macmillan (2020) Mouth Problems [Online] Available: https://www.macmillan.org.uk/cancer-information-and-support/impacts-of-cancer/mouth-problems [Accessed 9.4.2021] Marie Curie (2021) Mouthcare [ONLINE] Available: https://www.mariecurie.org.uk/professionals/palliative-care-knowledge-zone/symptom-control/mouth-care [Accessed 9.4.2021] National Institute for Clinical Excellence (2015) Guidance on care of the dying adult in the last days of life [ONLINE] Available: https://cks.nice.org.uk/topics/palliative-care-oral/management/end-of-life-care/ [Accessed 9.4.2021] National Institute for Clinical Excellence (NICE) (2018) Palliative Care Oral [online] Available: https://cks.nice.org.uk/topics/palliative-care-oral/management/oral-candida-infection/ [Accessed 9.4.20] Oral Health Foundation (2018) White Paper on Optimal Care and Maintenance of Full Dentures for Oral and General Health [Online] Available: https://www.dentalhealth.org/Handlers/Download.ashx?IDMF=8a8a723a-20c5-4064-8f37-1947ab94481a [Accessed 3.5.2021] Public Health England (2020) Mouth care for hospitalised patients with confirmed or suspected Covid 19. Available [online] Mouth care for hospitalised patients with confirmed or suspected COVID-19 - GOV.UK (www.gov.uk) Accessed 26.1.2021 Scottish Palliative Care Guidelines (2020) MOUTHCARE [ONLINE] Available: https://www.palliativecareguidelines.scot.nhs.uk/guidelines/symptom-control/Mouth-Care.aspx#:~:text=%20Mouth%20Care%20%201%20Introduction.%20Mouth%20care,semi-upright%20position%20to%20avoid%20choking%20or...%20Mor [Accessed 9.4.2021] Steel B J (2017 b) Oral hygiene and mouth care for older people in acute hospitals: part 2. Nursing Older People, 29, 10, 20-25.

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Appendix 1: Procedure Guidelines

Equipment for standard mouth care

Equipment Required Equipment provision If patient in hospital- hospital to provide supplies.

1.Small bowl Patient

2.Cup Patient

3.Water Patient

4.Small headed toothbrush/ moutheze oral cleanser Community nurses/ Hospice Team to supply moutheze

5.Toothpaste /SLS free toothpaste Patient

6.Disposable gloves & apron (refer to local infection control policy)

Nurse/ healthcare support worker providing mouthcare at time of visit

7.Disposable bag Nurse/ healthcare support worker providing mouthcare at time of visit

8. Pen torch / good lighting Nurse/ healthcare support worker providing mouthcare at time of visit

9.Denture pot (label if required) Patient

10.Gauze if dentures are present Nurse/ healthcare support worker providing mouthcare at time of visit

11.Mouthwash if prescribed Patient

12. Artificial Saliva product if indicated and prescribed

Patient

Procedure for delivering mouth care

Action Rationale

1. Explain and discuss the procedure with the patient.

To ensure that the patient understands the procedure and gives his/her valid consent.

2. Wash hands with soap and water/ antibacterial alcohol hand rub and dry with paper towel. Apply apron and disposable gloves.(refer to local infection control policy)

To reduce the risk of cross-infection.

3. Prepare solutions required.(refer to equipment for standard mouthcare)

Solutions must always be prepared immediately before use to maximize their efficacy and minimize the risk of microbial contamination.

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4. If the patient cannot remove their own dentures, using a tissue or piece of gauze, grasp the upper plate at the front teeth with the thumb and second finger and move the denture up and down slightly Lower the upper plate, remove and place in denture pot.

Removal of dentures is necessary for cleaning of underlying tissues. A tissue or topical swab provides a firmer grip of the dentures and prevents contact with the patient’s saliva. The slight movement breaks the suction that secures the plate.

5. Lift the lower plate, turning it so that one side is lower than the other, remove and place in denture pot once cleansed.

Lifting the lower plate at an angle helps removal of the denture without stretching the lips.

6. Remove a partial denture by exerting equal pressure on the border of each side of the denture.

Holding the clasps could result in damage or breakage.

7. Inspect the patient’s mouth with the aid of a pen torch and document oral assessment.

The mouth is examined for changes in condition with respect to moisture, cleanliness, infected or bleeding areas, ulcers, etc.

8. Using a soft, small toothbrush and pea sized amount of toothpaste brush the patient’s natural teeth, gums and tongue.

To remove adherent materials from the teeth, tongue and gum surfaces. Brushing stimulates gingival tissues to maintain tone and prevent circulatory stasis.

9. Hold the brush against the teeth with bristles at a 45˚ angle. The tips of the outer bristles should rest against and penetrate under the gum line. Then move the bristles back and forth using a vibrating motion, from the sulcus to the crowns of the teeth

10. Repeat until all teeth surfaces, front and back, have been cleaned. Interdental brushes enable cleaning between the teeth.

Brushing loosens and removes debris trapped on and between the teeth and gums. This reduces the growth medium for pathogenic organisms and minimizes the risk of plaque formation and dental caries.

11. Encourage spitting not rinsing. Paper tissues should be to hand. If the patient is immunosuppressed do not allow them to rinse directly into a sink.

Reservoirs of stagnant water may harbor Pseudomonas bacteria.

12. Apply artificial saliva product to the mouth if appropriate and/or suitable lubricant to dry lips.

To increase the patient’s feeling of comfort and well- being and prevent further tissue damage.

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13. When cleaning dentures: Brush, soak and brush again. A denture cleanser will help remove stains and leave your denture feeling fresher Dentists often recommend removing your dentures at night to give your mouth a chance to rest. If you remove your dentures, it is important to leave them in water to prevent any warping or cracking (Oral Health Foundation 2018).

Cleaning dentures removes accumulated food debris which could be broken down by salivary enzymes to products which irritate and cause inflammation of the adjacent mucosal tissue. Some commercial denture cleaners may have an abrasive effect on the denture surface. This then attracts plaque and encourages bacterial growth.

14. If oral candida present, dentures should be soaked in diluted antifungal if prescribed as per instructions.

Soaking in diluted antifungal reduces the risk of re-infecting the mouth with contaminated dentures.

15. Discard remaining mouthwash solutions.

To prevent the risk of contamination.

16. Rinse the toothbrush thoroughly and allow to dry (where possible stand toothbrush in upright position in small pot to air dry)

17. Wash hands with soap and water or alcohol hand-rub and dry with paper towel.

To reduce the risk of cross-infection.

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Appendix 2: Oral Care self-care – Advice for carers What self-care is recommended? Brush the teeth twice a day with soft toothbrush and fluoride toothpaste, spit do not rinse. Note: a 'sore mouth' toothpaste (SLS) may be better tolerated. Rinse the mouth after each meal and at night with warm water or 0.9% sodium chloride solution (readymade or made up if patient wishes).

o Irrigation with warm water or half a teaspoon of salt in 225ml water, helps to remove oral debris and is soothing and no traumatic.

If the tongue is heavily furred (especially if causing distress), brush across the tongue with a soft toothbrush twice a day and use an antiseptic mouthwash, such as chlorhexidine. Use chlorhexidine mouthwash if gum disease is diagnosed. For more information on mouthwashes, see Choice of Mouthwash. Take adequate fluids. Dry mouth Regular sips of water, sugar free sweets or artificial saliva may help. Artificial saliva with a neutral ph should be used with dentures. Clean debris from the teeth. Dental floss, or chewing pineapple (contains ananase, which is a cleansing enzyme), fresh or unsweetened, may help to remove debris. Mouth care should be done 2 hourly as a minimum to prevent oral problems especially in those with advanced disease or neurological impairment. Dentures should be removed at night and cleaned with a soft toothbrush and unperfumed soap or denture toothpaste. Seek the advice of a dentist regarding how to soak dentures overnight. Different strategies are used to soak dentures overnight. Some experts recommend the following options:

o Plastic dentures should be soaked overnight in a denture solution ie Milton (1 part Milton® 1 per cent to 80 parts of water).

o Dentures with metal parts should be soaked overnight in chlorhexidine solution (as sodium hypochlorite causes metal discolouration).

o Dentures should be rinsed well under running water before being returned to the mouth.

Basis for recommendation These recommendations are pragmatic and are based on expert opinion (NICE Palliative Care–Oral, 2018) A healthy mouth is clean, moist, and pain free. Regular mouth care will prevent or reduce the risk of many oral problems, such as infections. Maintaining oral hygiene is very important. The strategies for soaking dentures are based on expert opinion (Oral Health Foundation 2018)

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Appendix 3: Moutheze information leaflet

RDC ORDER CODE: ILA901

Working in partnership

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Appendix 4: Oral Assessment Tool

Working in partnership

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Appendix 5: The Denture Sunflower

Working in partnership

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Appendix 6: Mouthcare COVID-19 Guidance

Mouth care for non-ventilated patients (adults and children)

For non-ventilated patients:

• If patients are having oxygen via a face mask, check with the nurse in charge before removing this for the time needed to carry out mouth care

• assess the patient and consider if they can brush their own teeth, or if you need to help them to keep their mouth moist and clean

• these patients are more likely to cough when performing mouth care, be gentle, stand to the side or behind them, take breaks to allow the patient to rest and swallow

• if possible, sit the patient upright

• if the patient has a dry mouth, encourage sips of fluid (unless nil by mouth), hydrate with a toothbrush dipped in water or apply available dry mouth product to their tongue, inside of their cheeks and roof of their mouth. More information can be found in the video below

• make sure the patient’s lips are kept moist (with products available) particularly before cleaning

• if the patient can brush their own teeth give them a soft, small headed toothbrush with a smear of toothpaste (use non-foaming toothpaste if available)

• do not use an electric toothbrush as this may cause droplets and splash

• if the patient can spit, give the patient a disposable bowl to spit into

• if the patient is unable to spit and bedside suction is available, and you are trained to use it, then use gentle oral suctioning to remove excess saliva and toothpaste

• after brushing rinse their brush, and store with their toothpaste in a sealed named container or washbag

• if a patient has false teeth (dentures) encourage them to remove these after meals to clean off debris with a toothbrush. Remove dentures at night and store dry, in a named denture pot. Patients may not wish to wear dentures when unwell and it is important that they are stored in a named denture pot to avoid them getting lost

• if eating, encourage patients to have a few sips of water after meals to clear any left-over food from their mouth

• if a patient is confused, refuses, or resists care, stop and try again later. The video below explains more about this

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Mouth care for ventilated hospital patients - under the direction of the nurse in charge

Patients with COVID-19 will largely be ventilated because of viral pneumonia. Their mouths become very dry and will benefit from regular care to reduce the risk of getting bacterial pneumonia.

• before commencing mouth care check with the nurse in charge that this is appropriate and for any specific care advice

• work under the direction of the nurse in charge who will make sure that the endotracheal tube cuff is inflated to prevent aspiration, it is vital that you do not displace or disconnect the tube

• moisten the patients mouth with chlorhexidine mouthwash (or Corsodyl alcohol free mouthwash) using a green general oral swab or a soft toothbrush

• keep the patients lips moist with regular applications of products available

• dentures are likely to have been removed and should be stored dry in a named pot

End of life care

During end of life care:

• in the last days and hours of a patient’s life, keeping their mouth moist and comfortable is the main aim of mouth care

• continue to carry out mouth care if it is not causing distress

• if the patient has a dry mouth, hydrate with a toothbrush dipped in water or apply a dry mouth product to the tongue, inside of their cheeks and roof of mouth

• keep the patients lips moist with products available

Reference: Mouth care for hospitalised patients with confirmed or suspected Covid 19. Available [online] Mouth care for hospitalised patients with confirmed or suspected COVID-19 - GOV.UK (www.gov.uk) [Accessed 26.1.2021]

Working in partnership

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Review of document This document will be due for review in March 2024

Lincolnshire Community Health Services NHS Trust United Lincolnshire Hospitals NHS Trust

Lincolnshire Partnership NHS Foundation Trust

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Appendix 7 Equality and Health Inequality Impact Assessment Tool This tool has been developed by the Equality, Diversity and Inclusion Leads for use in the NHS Provider organisations in Lincolnshire. The tool is designed to ensure due regard is demonstrated to the Equality Act 2010, the Public Sector Equality Duty and potential health inequalities are also identified and addressed (as outlined in the Health and Social Care Act). Please complete all sections below. Instructions are in bold Email for all correspondence: email to lhnt.edifirst@nhs.net

Service or Workforce Activity Details

Description of activity This impact assessment applies to the guidelines for

mouthcare for adults who are palliative and/or end of

life

Type of change

Review of existing oral care policy

Form completed by Kay Howard, Macmillan Clinical Nurse Specialist

Date decision discussed

& agreed

Date

Who is this likely to

affect?

Service users □ X Staff □ X Wider Community □

If you have ticked one or more of the above, please

detail in section B1, in what manner you believe they

will be affected.

Equality Impact Assessment

Complete the following to show equality impact assessment considerations of the decision making to ensure equity of access and to eliminate harm or discrimination for any of the protected characteristics: age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, sexual orientation. Further, please consider other population groups which are at risk of health inequality and can include, but not be limited to, people who are; living in poverty / deprivation, geographically isolated (e.g. rural), carers, armed forces, migrants, homeless, asylum seekers/refugees, surviving abuse, in stigmatised occupations (e.g. sex workers), use substances etc.

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Please ensure you consider the connections (intersectionality) between the protected characteristics and population groups at risk of health inequality (e.g. it is recognised that older men from a BAME background, with one or more comorbidities and living in deprivation are more at risk of a poorer outcome if they contract CV-19).

How does this activity /

decision impact on

protected or vulnerable

groups? (e. g. their ability

to access services /

employment and

understand any changes?)

Please ensure you capture

expected positive and

negative impacts.

These guidelines do not have a negative impact on

protected or vulnerable groups.

What data has been/ do

you need to consider as

part of this assessment?

What is this showing/ telling

you?

Not applicable – the guidelines apply to all adults

accessing palliative and end of life care services

services

Risks and Mitigations

What actions can be taken

to reduce / mitigate any

negative impacts? (If none,

please state.)

N/A

What data / information do

you have to monitor the

impact of the decision?

N/A

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Decision/Accountable Persons

Endorsement to

proceed?

Yes / No Delete as appropriate and add detail or

rationale

Any further actions

required?

eg. risk to be added to the risk register or

capturing in local action log etc

Name & job title

accountable decision

makers

Date of decision

Date for review March 2022

Purpose of the Equality and Health Inequality Assessment tool

• The NHS in Lincolnshire has a legal duties under the Equality Act 2010,

Public Sector Equality Duty 2011 and the Health and Social Care Act 2012 to

demonstrate due regard in all decision making, for example, when making

changes to services or workforce practices, to ensure access to services and

workforce opportunities are equitable and to avoid harm and eliminate

discrimination for each of the protected characteristics and other groups at

risk of inequality.

• Within the guidance toolkit there are also some examples of decisions this

tool has been used on in other organisations and the impacts they have

identified.

Checklist

• Is the purpose of the policy change/decision clearly set out? □

• Have those affected by the policy/decision been involved? □

• Have potential positive and negative impacts been identified? □

• Are there plans to alleviate any negative impact? □

• Are there plans to monitor the actual impact of the proposal? □