The toothbrush is recognized as the most effective means of removing plaque and debris from the teeth and gums. A small‐headed, medium‐textured brush is most effective at reaching all areas of the mouth. Aids such as foam handles (available from occupational therapists) can make a manual toothbrush easier to hold (see Figure 9.16), and powered toothbrushes may be easier for patients with limited dexterity to use and have been shown to be as effective as manual toothbrushes (HEE [82]). For patients with a sore mouth, a soft or baby toothbrush can be used. The toothbrush should be allowed to air dry to reduce bacterial contamination, and in hospitals the toothbrush should be covered, ideally with a container for air circulation, rather than a plastic bag (HEE [82]).

Pre‐moistened mouth care sticks are impregnated with moisturizers and can be effective in aiding mouth comfort. The dry foam stick is one of the most common pieces of equipment used in hospital to moisten the mouth or soak up saliva secretions, although it is not effective to remove dental plaque (Binks et al. [19]), so they should not be used as an alternative to tooth brushing (Steel [218]). A national alert on their use was issued following a choking incident: it stated that prior to using them, care should be taken to ensure that the foam head is securely attached, to avoid risk of accidental detachment and aspiration (MHRA [130]). If used, sticks should not be left to soak in liquid but moistened immediately prior to being used and immediately discarded after use. Soaking sticks in liquid may detrimentally affect the strength of the foam head attachment. Patients and relatives using foam swabs should be made aware of their proper use (MHRA [130]).

The use of dental floss or other equipment is recommended to clean areas between the teeth that may be difficult to reach with a toothbrush (Birchenall and Streight [20]). Correct dental flossing or use of interdental cleaners once a day may help with plaque reduction, although these should be used with caution for patients with thrombocytopaenia or clotting disorders (UKOMiC [234]). A variety of equipment is available, such as dental floss, dental tape, wooden sticks and interdental brushes (Figure 9.17). For patients who have limited dexterity, this kind of cleaning may be difficult or impossible to carry out. Similarly, in patients with painful mouths or bleeding gums, this type of equipment can cause further discomfort, trauma and bleeding, and should be avoided. Oral irrigation devices such as the Waterpik® can be used for interdental cleaning. Oral irrigation uses a jet of water to remove debris and plaque and can be useful for people who find it difficult to use dental floss or tape, such as those with braces. Daily use of oral irrigation is safe and effective in addition to tooth brushing to remove biofilm from tooth surfaces and bacteria from periodontal pockets (Johnson et al. [95], Jolkovsky and Lyle [96]).

Toothpaste is a paste or gel used with a toothbrush (mechanical or powered) to clean and maintain the health of teeth and gums. It is an abrasive substance that aids in the removal of food from the teeth and dental plaque. Most of the cleaning is achieved by the mechanical action of the toothbrush and not by the toothpaste. Most toothpastes have active ingredients to help prevent tooth and gum disease. Toothpastes are composed of 20–42% water with abrasive components (to remove plaque and stains from the tooth surface), fluoride (to prevent cavities) and detergents (surfactants used mainly as foaming agents). Different types are listed in the Dental Practitioners’ Formulary (NICE [159]).

A pea‐sized amount of fluoride toothpaste should be used, and patients should be advised to ‘spit not rinse’ (spit out excess toothpaste but do not rinse out the mouth with water) to ensure that a film of toothpaste is left in contact with the teeth, allowing it to be absorbed. After tooth brushing, it is recommended that patients wait at least 30 minutes before eating or drinking (HEE [82]).

Mouthwashes are an adjunct to brushing and not a replacement. For those with active caries (decaying or crumbling teeth), dry mouth, orthodontic appliances or other risk factors, 0.05% (225 ppm) fluoride mouthwash is recommended (PHE [182]).

Several agents can be used to rinse the mouth, moisten the mucosa, and loosen and remove debris. Normal saline mouthwashes and saline sprays may provide some relief for dry mouth (UKOMiC [234]). Additional studies have shown some benefit in the use of saline for mouth care in cancer and elderly patients (Kim and Kim [98], McGuire et al. [126]). For patients with severe dry mouth, water‐based mouth‐moisturizing gels or sprays can be applied before mouth cleaning and eating so that these activities are less painful (HEE [82]); these gels and sprays are also helpful for tenacious secretions. Sodium bicarbonate has been used in some centres and oral hygiene regimes and can provide a good effect in dental decay prevention and have significant bactericidal activity (Giancio [75]). However, it can affect the mucosa, so its use should be reviewed after 48 hours.

Chlorhexidine gluconate is an effective antibacterial and antiplaque agent. For patients who are unable to use a toothbrush, it can provide a chemical method of stopping plaque build‐up. Chlorhexidine gluconate mouthwash used as an adjunct to mechanical oral hygiene can reduce dental plaque (HEE [82], James et al. [93]). Chlorhexidine mouthwash or gel reduces the risk of critically ill patients developing VAP from 25% to about 19% (Hua et al. [89], Veitz‐Keenan and Ferraiolo [236]). Longer‐term use is associated with altered taste, reversible staining of the teeth and parotid gland enlargement (Steel [218]). It should be avoided in patients receiving radiotherapy to the head and neck regions or patients who have mucositis; in these cases, preparations such as Caphosol®, Difflam®, Gelclair ® and MuGard ® are advocated (RD‐UK [196], UKOMiC [234]).

A number of agents widely used in the past for mouth care have been found to have detrimental effects and are no longer recommended. Glycerine and lemon swabs dehydrate the mucosa and exhaust salivary secretion, which acts to dry the mouth (NICE [155]). Hydrogen peroxide is also not recommended as it can cause mucosal abnormalities and pain (Consolaro [40]).

Fluoride helps to prevent and arrest tooth decay (HEE [82]), especially radiation caries, demineralization and decalcification. High‐dose fluoride toothpaste may be recommended for patients with current active caries, dry mouth or other predisposing factors, such as during and after receipt of radiotherapy treatment (PHE [182], RD‐UK [196], UKOMiC [234]).

For patients with salivary dysfunctions and dry mouth, saliva substitutes may help to alleviate these symptoms (Jawad et al. [94]). There are a variety of products available, such as artificial saliva replacements and salivary stimulants (Jawad et al. [94], NHS HEE [82]). Current recommendations suggest avoiding artificial saliva products with an acidic pH due to the increased risk of dental decay, and instead choosing preparations with fluoride (RD‐UK [196], UK Medicines Information [233], UKOMiC [234]).

A coating agent can be used to coat the surface of the mouth, forming a thin protective film over painful oral lesions or for patients with mucositis. Oral lesions and mucositis can be caused by medication, disease, oral surgery, stress, traumatic ulcers caused by dental braces and dentures, radiotherapy and chemotherapy. Examples of coating agents include Caphosol®, Difflam®, Episil®, GelClair® and MuGard® (RD‐UK [196], UKOMiC [234]). These products should be rinsed around the mouth to form a protective layer over the sore areas, and generally applied 1 hour before eating. Several agents can be used to coat the oral mucosa and they are thought to have a protective effect although there is limited evidence to support their use (Saunders et al. [204]). Sucralfate has not been shown to be effective in preventing or treating chemotherapy‐ or radiotherapy‐associated oral mucositis (Saunders et al. [204]).

Colonization of the mouth with yeast occurs in one‐third of the population. In patients receiving steroids or antibiotics, the balance of the oral flora can be altered and oral candidiasis (oral thrush) can occur. Predisposing factors also include xerostomia, poor oral health and the presence of dentures. These infections can be treated with either topical or systemic antifungal medications. In debilitated or immunocompromised patients, candidiasis can become a systemic infection.

Antifungal agents are a group of drugs specifically used for the treatment of fungal infections. A number of preparations are available. Selection should be based on location and severity of infection (HEE [82]). Oropharyngeal candidiasis can be treated with either topical antifungal agents (e.g. nystatin, clotrimazole or amphotericin B oral suspension) or systemic oral azoles (fluconazole, itraconazole or posaconazole). Length of treatment depends on the pharmacological agent chosen and recommendations regarding their relevant pharmacology. Local prescribing guidelines should be followed.