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Introduction 

This guidance has been written by a group of RCSLT members with experience and expertise working with adult patients with compromised mouth care across a range of settings and geographies. It aims to help speech and language therapists (SLTs) working with these patients by providing best practice guidelines for providing mouth care. These guidelines should be used in the context of working within a multidisciplinary team (MDT).

Authors


  • Lynsay Anderson
  • Kathryn Harnett
  • Aideen Kavanagh
  • Hannah Leckey
  • Jasper McKenzie
  • Carolee McLaughlin
  • Jackie McRae
  • Lisa Partridge 
  • Rachel Sylla

With thanks also to the Special Care Dental team at the South Eastern Health and Social Care Trust, Angela Crocker, and everyone who responded to the consultation on this document.


If you have any feedback on this guidance, please contact us

Mouth care in speech and language therapy

Routine mouth care


Mouth care is the practice of maintaining a clean and comfortable mouth and preventing oral infection. Mouth care comprises cleaning teeth, dentures, tongue, gums and palate and maintaining healthy oral mucosa. There is an increasing wealth of evidence on the link between oral health and general health. Good mouth care maintains self-esteem, comfort, and the person’s ability to communicate, socialise, and enjoy food and drink. The World Health Organization defines good oral health as “a state of being free from mouth and facial pain, oral diseases and disorders that limit an individual’s capacity in biting, chewing, smiling, speaking and psychosocial wellbeing” (World Health Organization, 2020). There is increasing evidence to link poor oral health to systemic diseases including cardiovascular disease and diabetes (Winning et al 2015). 


Oral health can be affected by sarcopenia, cognitive decline, surgery, neurological disorders, requirement for oxygen, dependence and levels of consciousness. Medications, radiotherapy, enteral feeding and nil by mouth status can have an impact on oral health as they may cause xerostomia and hyposalivation. 


Routine mouth care is the shared responsibility of the patient wherever possible and the multidisciplinary team (MDT), carers and family members involved in their care. It should be a routine part of basic daily care and preventing oral infection carried out in line with a patient-centred approach.


SLT role in mouth care


For some patients, SLTs may use their specialist knowledge in communication and dysphagia to integrate mouth care into assessment and intervention planning in a variety of acute and community settings, such as hospitals, care homes and people’s own homes. Patients with higher levels of need with eating, drinking and swallowing difficulties may require SLT input regarding their mouth care plan. See the RCSLT dysphagia competency framework. This could include (but is not limited to):

 

  • oncology patients;

  • people with learning disabilities;

  • patients in palliative care;

  • neurodisability patients (eg stroke, progressive neurological disorder, dementia);

  • patients requiring respiratory support in critical care

  • patients undergoing oral surgery

  • patients taking dietary supplements

  • patients on a modified diet and fluids; and

  • those reliant on others for daily care.


Dysphagia is considered an important risk factor for developing aspiration pneumonia, but generally not sufficient enough to cause pneumonia without the presence of other risk factors as well, such as decayed teeth and dependency for oral care (Langmore et al, 1998). Poor oral health, for example presence of dental bacterial plaque, is related to higher rates of aspiration pneumonia and adults with dysphagia are also more likely to present with poor oral health, eg with visible dental bacterial plaque and food debris leading to gingivitis (bleeding gums), periodontal disease and dental caries (Ortega et al, 2014). Mouth care in the form of toothbrushing, gum/tongue brushing with fluoridated toothpaste, mouthwashes eg chlorhexidine (or gels if there is risk of aspiration) and the removal of secretions/food residue can reduce pneumonia rates (Yoneyama et al, 2002) and should therefore be part of dysphagia care planning. 


Poor mouth care can impact on a person’s ability to communicate due to discomfort and/or dry mouth/xerostomia affecting clarity of speech and voice. In addition to reduced dexterity, language and cognitive impairments can limit their ability to carry out and participate in a mouth care regime. This may have an impact on quality of life; for example, halitosis or painful mouth and teeth. 

 

Mouth care in the context of COVID-19

 

The importance of good mouth care became even more apparent at the beginning of the COVID-19 pandemic. The need for respiratory support via face masks, continuous positive airway pressure (CPAP) or endotracheal tube causes drying of the oral mucosa, exacerbated by reduced hydration and oral intake. People who were intubated and sedated for extended time, developed ulcerations to the lips, tongue and soft palate. Some also experienced swollen tongues due to prolonged tube contact. In cases of people being in a prone position for a long time, some experienced wounds to the mouth and cheeks due to their inability to manage secretions. There is some research underway exploring the link between oral hygiene and the severity of COVID-19 (Sampson et al, 2020).

 

Mouth care is not currently classified as an aerosol generating procedure (AGP). However, it is important to refer to up-to-date national and local guidance; for example, Public Health England guidance on mouth care for hospitalised patients with confirmed or suspected COVID-19. See the RCSLT guidance on reducing risk of transmission, use of personal protective equipment (PPE) in the context of COVID-19) for a risk assessment around PPE if required.

Best practice guidelines for SLTs delivering mouth care 

Knowledge and training 

  • We recognise that there is a lack of formal training in this area but would encourage SLTs to seek informal or formal training to understand the risks and benefits of delivering mouth care. This could be e-learning, workplace learning, peer review, journal clubs and linking in with specialist teams/dentists/oral health promoters. It is likely that SLTs will be advocating for the importance of mouth care due to the potential impact on communication and swallowing so they require a theoretical understanding. Until formal training is available, best practice would be to review these skills in collaboration with other colleagues eg nurses, health care assistants, and a wide range of caregivers, especially in the community setting.

  • SLTs should incorporate mouth care education as part of their continuing professional development (CPD) from other organisations or oral health specialists (eg dentists, dental hygienists, local and national guidelines and protocols, Mouth Care Matters) to acquire the necessary skills and knowledge to address the common conditions mentioned under ‘assessment and ongoing management’ below. It is advisable to connect with multidisciplinary teams (MDTs) and local oral health promotion teams for advice and support.

  • It is best practice for SLTs to support and educate patients, their family/support networks and the MDT to access appropriate mouth care in the context of communication and swallowing difficulties. For example, advising the patient on appropriate equipment (eg mirror, torch, small headed soft toothbrush, low foaming toothpaste, or suction toothbrushes for high risk dysphagia patients) and how to access it.

Collaborative working

  • A collaborative approach to oral health is essential. The oral assessment should identify patients who are at a higher risk and who may need further input for advice regarding oral hygiene or dental care. SLTs should signpost their patients to other relevant services where required, for example, to treat oral infections, to advise on products for secretion management, or to advise on bite/mouth guards. This could include (but is not limited to):

    • dental services;

    • special care dentists;

    • nurses;

    • GPs; 

    • pharmacists; 

    • oral and Maxillofacial surgery (OMFS); 

    • ear, nose and throat (ENT); and

    • allied health professions (AHPs) - physiotherapists, occupational therapists and dietetics.

 

For more information on the different roles of professions, see the Mouth Care Matters guide for hospital healthcare professionals.

Additional considerations

  • Additional support or adjustments for patients with communication impairment may be required, such as providing resources in alternative formats (eg easy read, pictorial). 

  • If there are concerns about a patient's capacity to consent to or refuse mouth care, you should consider carrying out a mental capacity assessment in accordance with legislation (Mental Capacity Act 2005 in England and Wales; Adults with Incapacity (Scotland) Act 2000 in Scotland; Mental Capacity Act (NI) 2016 in Northern Ireland). See the RCSLT supported decision-making and mental capacity guidance.

Assessment and ongoing management 

  • An oromotor examination is an essential component of a speech and language therapy assessment of both swallowing and communication ability. Components of an oral health screen are often included during the oromotor assessment and include, but are not limited to, the following:

    • assessment of lips, gums, mucous membranes, palate, tongue, teeth/ dentures, chewing function; 

    • full cranial nerve assessment of motor and sensation may be included where clinically appropriate; and

    • assessment of dependence as a result of physical limitations, cognition or behaviour which may affect ability to perform and maintain oral hygiene.

  • SLTs should be able to identify the main common conditions associated with poor oral hygiene (and seek training from other professionals where needed), these include but are not limited to:

    • candida;

    • ulcers;

    • red/white patches;

    • periodontal disease or bleeding gums;

    • broken teeth or dentures;

    • plaque;

    • food debris;

    • halitosis;

    • dental or oral pain;

    • hypersensitivity;

    • reduction in taste; and

    • hypersalivation or xerostomia.

Nb It is acknowledged that an oral hygiene assessment by an SLT is not a dental examination and that a routine dental exam would still be required for all patients.

  • There are many oral health screening tools available, below are some that offer good validity and reliability:

    • The Holistic and Reliable Oral Assessment Tool (THROAT);

    • Brief Oral Health Status Examination (BOHSE);

    • Oral Health Assessment Tool (OHAT); 

    • The Oral Assessment Guide (OAG); and

    • Mouth Care Matters Assessment Guide. 

  • Following assessment, ongoing monitoring should be discussed and agreed with other professionals/members of the MDT as needed. SLTs should know when to refer to appropriate departments if they identify abnormalities in the mouth.

Secretion management

  • It is key that SLTs understand the cause of any secretion management issues (eg a side effect of medication, the effect of radiotherapy, impact of suboptimal posture/head support, or oxygen requirements) in order to participate in the MDT decision making process around treatment of the resulting conditions.

  • A secretion management plan should be based on a patient’s needs identified through assessment and MDT discussion. It is important to ensure that the method of application is safe for those with dysphagia. Products are available in different formulations (eg spray and gel) and may need to be applied by a carer. Guidance should be given on safe application to avoid risk of injury or aspiration when placing intra-orally.

Dry mouth/xerostomia

  • Various dry mouth products are available. (See the RCSLT mouth care resources). Be aware of ingredients and check for allergies or religious restrictions. SLTs should work with the MDT and the patient to develop a dry mouth management plan to maximise oral intake (where clinically appropriate) and communication. 

  • Be aware that foam swabs can present a choking risk. See MHRA alert for further information (MHRA, 2012).

  • Be aware of the evidence that lemon and glycerine swabs can worsen dry mouth/xerostomia as they cause overstimulation and exhaustion of the salivary glands (NICE, 2018).

  • SLTs have a role in assessment and management of oral hydration for dysphagic patients. This could include liquid or gel based products for patients with severe dysphagia. Risk feeding may include sips of water or ice chips for comfort. (See the RCSLT mouth care resources)

Hypersalivation

  • Oxygen therapy may cause dry mouth/xerostomia and dry cracked lips. For patients receiving oxygen therapy, water-based products (eg mouth gel) should be used rather than petroleum jelly-based products (Bauters et al, 2016).

  • Consultation with the medical, dental and pharmacy teams is required to consider treatment options for hypersalivation. The Motor Neurone Disease Association has useful information on hypersalivation management: managing saliva problems in motor neurone disease.

  • Other management considerations may include steam inhalation or nebulisers, optimising positioning to support excess saliva or consider use of appropriate tools such as a suction toothbrush.

Pain 

  • Medical management of oral pain is important for a specific cohort of patients who are at risk of experiencing significant pain from oral mucositis (eg oncology patients) as a side effect of diagnosis and treatment. This can impact on keeping the mouth clean and comfortable. Swallowing, communication, and nutrition can also be negatively impacted.

  • Monitor closely for any trauma and pain (eg bleeding to lips) that may require signposting to maxillofacial or dental teams for advice on mouth/bite guards and analgesia if needed.

  • Patients with high levels of spasticity in the oral cavity often have poor mouth access (eg those with complex brain injury). Botulinum toxin may be used to release tightness in the masseters (Bayet et al, 2018). 

Hypersensitivity

  • Assess for signs of oral hypersensitivity. Most commonly, withdrawal responses such as reduced tolerance to touch around the face and/or mouth (may extend to the rest of the body), facial grimacing, abnormal oral reflexes such as bite reflex and bruxism (teeth grinding). These can often lead to difficulties providing oral care.

  • Consider implementing a desensitisation procedure to alleviate the above symptoms prior to commencing mouth care (Gilmore et al, 2003). If issues persist, discuss use of pharmacological interventions. See the Mouth Care Matters Oral Hypersensitivity fact sheet.

Intensive care unit (ICU)

  • ICU patients receiving mechanical ventilation are at higher risk of nosocomial infection which can cause ventilator associated pneumonia (VAP). Therefore, oral hygiene should be considered a core part of the care provided in ICU by the MDT (Berry et al, 2007).

  • Be aware that patients that are intubated with endotracheal tubes are at risk of developing ulcerations to the lips, tongue and soft palate, as well as damage to the teeth. 

  • Following oral surgery, it is important to take extra care when providing mouth care around the surgical site. In the acute stages following complex surgeries in particular, it is best practice to discuss mouth care provision with the MDT, including the use and frequency of suctioning, toothbrushes, toothpaste and mouth rinse.     

  • Chlorhexidine has been found to be better at reducing bacterial infection in comparison to it not being used (Sharifah, 2016). However, for patients with VAP, it is important to consider emerging evidence which has shown increased mortality among these patients associated with decontamination with oral chlorhexidine (Hellyer et al, 2016). In all cases, regular mouth care helps to reduce the build-up of biofilm and oral gels help to restore moisture and replace salivary enzymes.

References

To see a full list of references please download these references as a PDF