Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed. Where possible, encourage patients to carry out their own oral care.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [162], C). To enable patients to gain confidence in managing their own symptoms (NHS England [144], C).
2. 2.Show
   Wash hands with soap and water and dry with a paper towel, or use alcohol‐based handrub. Put on disposable gloves.
   To reduce the risk of cross‐infection (NHS England and NHSI [148], C).

Procedure

1. 3.Show
   Carry out an oral assessment using an approved oral assessment tool. See Figure 9.15.
   To provide a baseline to enable monitoring of mucosal changes and evaluate the patient's response to treatment and care (HEE [82], C).
2. 4.Show
   1. Inspect the patient's mouth, including the teeth, with the aid of a torch, spatula and gauze, paying special attention to the lips, buccal mucosa, lateral and ventral surfaces of the tongue, floor of the mouth and soft palate (Action figure 9.18).
   2. Ask the patient whether they have any of the following: taste changes, change in saliva production or composition, oral discomfort or difficulty swallowing.
   The mouth is examined for changes in condition with respect to moisture, cleanliness, infected or bleeding areas, ulcers and so on. These areas are known to be particularly susceptible to cytotoxic damage (HEE [82], C).

   To assess nutritional deficits, salivary changes and pain secondary to oral changes (HEE [82], C).
3. 5.Show
   Using a small‐headed, medium‐texture toothbrush and toothpaste, begin to brush the patient's natural teeth, gums and tongue. Small circular brushing movements are recommended.
   To control gum disease. The physical removal of plaque is the important element of tooth brushing as it reduces the inflammatory response of the gingivae and its sequelae (HEE [82], C; PHE [182], C). Small circular brushing movements enhance plaque removal (Peterson et al. [180], C; PHE [182], C).
4. 6.Show
   Hold the brush against the teeth with the bristles at a 45° angle. The tips of the outer bristles should rest against and penetrate under the gingival sulcus. Using the tips of the bristles, vibrate back and forth with short, light strokes for a count of 10, allowing the tips of the bristles to enter the sulcus and cover the gingival margin. Lift the brush and continue on to the next area or group of teeth until all areas have been cleaned. After the vibratory motion has been completed in each area, sweep the bristles over the crowns of the teeth, towards the biting surface. The toe bristles of the brush can be used to clean the lingual (tongue) anterior area in the arch.
   Brushing loosens and removes debris trapped on and between the teeth and gums (HEE [82], C). This reduces the growth medium for pathogenic organisms and minimizes the risk of plaque formation and dental caries (PHE [182], C).
5. 7.Show
   Ask the patient to spit out excess toothpaste into the receiver or bowl but do not allow them to rinse the mouth out with water.
   To ensure that a film of toothpaste is left in contact with the teeth, allowing it to be absorbed (HEE [82], C).
6. 8.Show
   Floss teeth (unless contraindicated due to conditions such as clotting abnormality or thrombocytopenia) once every 24 hours using lightly waxed floss.

   1. To floss the upper teeth, use your thumb and index finger to stretch the floss and wrap one end of the floss around the third finger of each hand. Move the floss up and down between the teeth from the tops of the crowns to the gum and along the gum lines wherever possible (Action figure 9.19).
   2. To floss the lower teeth, use the index fingers to stretch the floss.
   Flossing helps to remove debris between teeth (UKOMiC [234], C).

   Flossing when a patient has abnormal clotting or low platelets may lead to bleeding and predispose the oral mucosa to infection (American Cancer Society [6], C; Elad et al. [58], C).

Post‐procedure

1. 9.Show
   Discard remaining mouthwash solutions.
   To prevent infection (Bullock and Manias [28], E).
2. 10.Show
   Clean the toothbrush and allow it to air dry.
   To reduce the risk of contamination (HEE [82], C).
3. 11.Show
   Remove gloves. Decontaminate hands.
   To reduce the risk of cross‐infection (NHS England and NHSI [148], C).
4. 12.Show
   Ensure the patient is comfortable.
   To maintain patient comfort and dignity (NMC [162], C).
5. 13.Show
   Advise the patient not to eat or drink within 30 minutes of brushing (HEE [82]).
   To ensure that a film of toothpaste is left in contact with the teeth, allowing it to be absorbed (HEE [82], C).