If the person requires assistance with oral care:
- Oral care should be offered at least four times daily or as tolerated. Some people may need more frequent care, particularly when they are no longer able, or have reduced ability to eat or drink.
- Where possible, identify and manage the underlying cause, for example, review medication, manage anxiety, treat intraoral infection, humidify oxygen and if appropriate encourage hydration.
- Gently remove coatings, debris and plaque from soft tissues, lips and mucosa.
- Failing to remove dried secretions, debris and plaque gently can cause pain, ulceration and bleeding, and predispose to infection.
- Use a soft bristle, small-headed toothbrush to remove debris. Alternative toothbrushes for people with limited ability to open their mouths are available.
- An alternative is to use damp non-fraying gauze (that has been thoroughly wetted in clean, running water) wrapped around a gloved finger to gently soak coated areas, provided it is safe to do so.
- Oral swabs with foam heads SHOULD NOT be used as heads may detach during use.
If the person is able to take part in oral care:
- Encourage hydration. Cold, unsweetened drinks (such as sips of water) should be offered frequently throughout the day if desired and safe. Sucking crushed ice or frozen tonic water may provide relief.
- Saline mouthwashes may help to clean the mouth. People in hospital may use 0.9% sodium chloride from a vial followed by rinsing with cold or warm water. For people 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 person is able to understand how they are used and use them safely.
Denture care
Denture wearers in the last days of life may have specific mouth care needs.
Comfort considerations:
- Consider whether continuous denture use is necessary for comfort and dignity. Dentures can be left out at night or for extended periods to improve comfort, especially if the mouth is sore. Always discuss this option with the person and their family and get their consent.
- Address potential concerns from family members who might be unfamiliar with seeing their loved one without dentures. Clear communication and explanation about comfort being a priority is important.
Denture hygiene:
- If dentures are being worn, continue cleaning them daily with a soft brush and a denture cleanser following the manufacturer's instructions. Denture hygiene is still important to prevent fungal infections.
- When not in use, dentures should be soaked in a denture cleaning solution overnight.
Communication:
- Ensure clear communication with the person and family about denture care options and address any questions or concerns they may have.
Additional points:
- If the person is unable to clean their dentures themselves, a caregiver or healthcare professional can assist them.
- If the person has dentures with clasps or other metal parts consult your dentist about appropriate cleaning solutions to avoid damage.
- Regularly inspect dentures for cracks or chips, as these can irritate the gums.
Saliva substitute products:
- Saliva substitutes (for example, oral gel, spray or mouth rinse) may be used if other measures are insufficient. Refer to local formulary and the British National Formulary (BNF).
- There is no strong evidence that topical therapy is effective for relieving xerostomia, but many people find it useful. The ideal product should be acceptable to the person, 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 (for example, AS Saliva Orthana® products contain mucin of porcine origin).
- Topical artificial saliva and saliva stimulant products should be used as frequently as needed, including before and during meals.
- Enough artificial saliva should be used to cover the whole mouth. Applying artificial saliva under the tongue can help spread the artificial saliva around the whole mouth.
- Attention should also be paid to the lips. Applying a water-based product will help to prevent or treat cracked lips.
- 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.
- If a preparation without fluoride is used, a daily fluoride mouthwash should also be used in dentate patients.
- Fluoride mouthwash (0.05%) can be used at a different time from brushing.
- A dry mouth can contribute to tooth decay. Where appropriate, people should be encouraged to attend their dentist regularly for assessment and necessary treatment.
Information relating to allergens, dietary or cultural aspects of most frequently used saliva substitutes:
| AS Saliva Orthana® Spray | Use 2–3 sprays as required onto oral and pharyngeal mucosa. Contains pig mucin so it is not suitable for vegetarians, vegans or those following Halal or Kosher diets. |
| BioXtra® Dry MouthSpray | Spray onto gums, tongue and lips as required. |
| BioXtra® Dry Mouth Oral Gel | Apply with a clean finger or swab onto gums, tongue and under dentures. Apply as required particularly at night. Contains gluten and traces of milk and egg white proteins. |
| Biotene® Moisturising Mouthwash | Use approximately 15mL, rinse for 30 seconds then spit out. Use up to a maximum of five times per day unless otherwise instructed. |
| Biotene® Oral Balance Moisturising Gel | Place 1–2 cm of gel directly onto the tongue and spread thoroughly inside the mouth. This can be repeated as often as necessary. Gel can also be placed on a clean or gloved finger and applied directly into the mouth |
For further information, please refer to:
https://www.sps.nhs.uk/articles/what-should-be-considered-when-choosing-or-prescribing-saliva-substitutes/
NHS England summarises the evidence for diseases linked to poor mouth care.
https://youtu.be/Ge9WGTp5y3o?si=zjCprwMXvaMQwQpD NHS England - clear message on pink sponges (oral swabs with foam head) and demonstration of alternatives