Definitions for the grades of recommendations (A, B, C, D) and the levels of evidence (1++ to 4) are provided at the end of the Major Recommendations field.
Assessment
Guideline 1: Oral Assessment Guide
Use Oral Assessment Guide (OAG) (adapted from Eilers, Bergers, & Peterson, 1988; refer to Annex 1 of the original guideline document) on patients identified as requiring assistance with oral hygiene during routine assessment. (C/2++)
Guideline 2: Oral Assessment Category
The following eight categories should be assessed daily using the three ratings:
1 = Normal findings
2 = Mild abnormality without compromise of either mucosal integrity or loss of function
3 = Severe abnormality with compromise of either mucosal integrity or loss of function (B/2++)
- Voice
Communicate with patient and listen whether
- The voice is normal; or
- The voice is deep/raspy (hoarse); or
- Patient has difficulty talking or experienced pain
- Swallow Reflex
Ask patient to swallow and observe whether
- The swallowing is normal; or
- Patient experiences some pain on swallowing; or
- Patient is unable to swallow
- Lips
Observe lips and assess whether they are
- Smooth, pink, moist; or
- Dry or cracked; or
- Ulcerated or bleeding
- Tongue
Observe the tongue and assess whether it is
- Pink, moist, and papillae present; or
- Coated or there is loss of papillae with a shiny appearance, with or without redness; or
- Blistered or cracked
- Saliva
Insert a spatula into mouth, touching the centre of the tongue and the floor of the mouth and observe whether
- The saliva is watery; or
- The saliva is thick; or
- There is absence of saliva
- Mucous Membrane
Observe the mucous membrane in the oral cavity and determine if it is
- Pink and moist; or
- Reddened or coated (increased whiteness) without ulceration; or
- Ulcerated with or without bleeding
- Gingiva (Gums)
Gently press the gums with end of spatula and observe whether
- They are pink and stippled and firm; or
- They are oedematous with or without redness; or
- There is spontaneous bleeding or bleeding with pressure
- Teeth or Denture Bearing Area
Observe the appearance of the teeth or denture bearing area and determine whether
- They are clean with no debris; or
- There are plaque or debris in localized area (between teeth if present); or
- There are plaque or debris generalized along gum line or denture bearing area
Guideline 3: Recommended Intervention
Nursing interventions should be based on the rating for each category. (D/4)
| Rating |
Description |
Nursing Interventions |
| 1 |
Normal findings |
Continue with routine oral care
No treatment |
| 2 |
Mild abnormality |
Continue with routine oral care
Close monitoring
Inform primary doctor
|
| 3 |
Severe abnormality |
Perform oral care with caution
Inform primary doctor
Perform treatment as ordered |
Guideline 4
Institutions should establish the frequency of performing oral assessment for patients that is sensitive and specific to their clinical settings. (D/4)
Oral Cleansing Methods
Toothbrushes
Guideline 1
Toothbrushing
Toothbrushing should be the first line of oral cleansing method unless the patient is prone to bleeding, pain, or aspiration. (C/2++)
Guideline 2
Frequency of Toothbrushing
Brush teeth at least twice a day, preferably soon after awakening in the morning and before going to bed. (D/4 - Adair et al., 2001)
Guideline 3
Use soft-bristled, small-ended toothbrush.
(D/4 - Dykewicz et al., 2000; Madeya, 1996; Miller & Kearney, 2001)
Foam Swabs
Guideline 1
Use foam swabs/brushes with chlorhexidine or toothpaste when toothbrushing is not advisable, for example, in the elderly or patients with bleeding tendency. (D/4 - Griffiths et al., 2000)
Guideline 2
Do not use foam swabs for longer than necessary. (B/2++)
Mouth Square
Guideline 1
Do not use mouth square/cotton square/gauze. (D/4)
Oral Cleansing Agents
Guideline 1
Fluoride Toothpaste
Brush teeth with fluoride toothpaste twice daily for the prevention and control of dental caries. (A/1+)
Guideline 2
Glycerine-Based Products
Avoid glycerine-based oral cleansing agents. (D/4 – Bruner et al., 1998)
Guideline 3
Glycerine-Based Products With Lemon
Do not use glycerine-based products containing lemon. (D/4)
Guideline 4
Sodium Bicarbonate
Use appropriately diluted (according to manufacturer's instruction) sodium bicarbonate for dissolving viscous mucous. (D/4)
Guideline 5
Hydrogen Peroxide
Hydrogen peroxide should be used only upon the advice or prescription of the physician or dentist. It is not recommended for daily routine use. (A/1+)
Guideline 6
Chlorhexidine Mouthwash
Use chlorhexidine mouthwash twice daily as prescribed to complement oral care procedures. (B/1+)
Guideline 7
Normal Saline Mouthwash
Use normal saline mouthwash for patients with oral lesions. (D/4)
Frequency of Oral Hygiene
Guideline 1
The frequency of oral hygiene should be determined by patient comfort and the status of the oral cavity. It should be performed at least twice a day. (D/4)
Denture Care
Guideline 1
Clean dentures with a denture brush/ toothbrush and soap/ toothpaste at least once daily. Chemical denture-cleansing agents can be used in addition to cleaning with soap and water. Rinse off the cleansing agent before use. (D/4 - Johnson & Chalmers, 2002)
Guideline 2
Soak dentures in clean water or with commercial denture-cleansing agents at night or when not worn. (D/4 - Johnson & Chalmers, 2002)
Guideline 3
Clean denture storage container with soap and water or dispose it at least once a week. (D/4 - Johnson & Chalmers, 2002)
Guideline 4
Date and label patient's name on all denture storage containers. (D/4 - Johnson & Chalmers, 2002)
Patient Education
Guideline 1
The healthcare worker should involve the patient and his caregiver in the oral hygiene programme. (D/4)
Definitions:
Individual Study Validity Ratings
++
All or most of the criteria have been fulfilled. Where they have not been fulfilled the conclusions of the study or review are thought very unlikely to alter.
+
Some of the criteria have been fulfilled. Those criteria that have not been fulfilled or not adequately described are thought unlikely to alter the conclusions.
-
Few or no criteria fulfilled. The conclusions of the study are thought likely or very likely to alter.
Study Design Designation
The study design is designated by a numerical prefix:
"1" for systematic reviews or meta-analyses or randomised controlled trials (RCTs)
"2" for cohort and case-control studies
"3" for case reports/series
"4" for expert opinion/logical arguments/"common" sense
Hierarchy of the Levels of Scientific Evidence
Each study is assigned a level of evidence by combining the design designation (1, 2, 3 or 4) and its validity rating (++, + or -). The meanings of the various "levels of evidence" are given below:
1++
High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias
1+
Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias
1-
Meta-analyses, systematic reviews, or RCTs with a high risk of bias
2++
High quality systematic reviews of case-control or cohort studies
High quality case-control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+
Well-conducted case-control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2-
Case-control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3
Non-analytic studies (e.g. case reports, case series)
4
Expert opinion
Categories of the Strength of Evidence Associated with the Recommendations
A
At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population; or
A body of evidence, consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B
A body of evidence, including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C
A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D
Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Interpretation of the D/4 Grading
The grading system emphasises the quality of the experimental support underpinning each recommendation. The grading D/4 was assigned in cases where:
- It would be unreasonable to conduct a RCT because the correct practice is logically obvious
- Recommendations were derived from existing high quality evidence-based guidelines. The guideline developers alert the user to this special case by appending the initials of the source in the original guideline document, e.g. (D/4 - Fantl et al., 1996)
