51
Mouth care – A Quality improvement project Dr Matthew Doré The Hundred House, 10 May 2016
Mouth care ndash A Quality improvement project
Dr Matthew Doreacute
The Hundred House 10 May 2016
What is a Quality improvement project An audit has the audit cycle to measure what we do against defined standards Not everything has standards defined has unclear or no guidelines Some of these things would improve quality of patient and staff with general common sense A QI projects allows incremental and measurable changes to make a difference to patientsrsquo care bull More flexible and dynamic
bull if something does not work to scrap it
bull employs multiple changes
Dry Mouth (aka Xerostomia)
Highly prevalent symptom in palliative care
Incidence of 60-80 in patients with advanced cancer (PANG 2011)
Risk factors includehellip
1) Medications
2) Mouth breathing
3) Advanced age
4) Previous history of radiation to the head and neck
5) Sjoumlgrenrsquos syndrome (the SICCA syndromes)
6) Diabetes mellitus (or vascular diseases)
7) Anxiety states 8) Dehydration
Medications seem to be the significant cause of Xerostomia in palliative carerdquo - (1)
ldquoA median number of four drugs they were associated with xerostomia - (2)
ldquoDry mouth can alter taste and make it difficult for patients to eat and swallow and
may also complain of mouth pain and difficulty with speakingrdquo ndash (2)
- Swallow tablets eat drink effectively
1) Davies AN Broadley K Beighton D Xerostomia in patients with advanced cancer J Pain Symptom Manage 2001 22820
2) Sweeney MP Bagg J The mouth and palliative care Am J Hosp Palliat Care 2000 17118
Medications
bull Xerostomia is a significant problem for many palliative patients with an incidence
of 60-80 in patients with advanced cancer and those being admitted to hospice units
(PANG guidelines 2011)
bull NICE highlights that when managing xerostomia in a palliative population individual
patient preference is likely to influence product acceptability and compliance (NICE
2012 Palliative Cancer Care - Oral)
bull A Cochrane review on the interventions for management of dry mouth (which was not
specific to the palliative care population) did not identify any strong evidence that any
topical therapy is effective for relieving the symptoms of dry mouth (Furness S et al
2011)
bull There are to date no randomised controlled trials demonstrating a superiority of any
individual mouth care products or oral saliva replacement products to each other in a
palliative population
bull Systematic literature review Xerostomia in advanced cancer patients (Supportive Care
in Cancer vol 23(3) Oct 2014)
bull The aim of this review was to determine the effectiveness of pharmacological and non-
pharmacological interventions in treating xerostomia in adult advanced cancer patients
Literature Search
bull Results
ndash 3 RCTs and 3 prospective studies
ndash Compared acupuncture pilocarpine Saliva Orthana and chewing gum with placebo
ndash All interventions were considered effective in treating xerostomia to equal effect
ndash However effectiveness versus placebo often could not be demonstrated statistically significantly
ndash No meta analysis possible ndash too small
bull Conclusion
ndash Limited published data exists so no firm conclusions can be drawn
ndash However pilocarpine artificial saliva chewing gum and acupuncture have some evidence
ndash This highlights the explicit need to improve our evidence base Properly constructed RCTs are
required
bull Systematic literature review Xerostomia in advanced cancer patients (Supportive Care in
Cancer vol 23(3) Oct 2014)
bull Palliative Medicine as a whole recommend a variety of oral saliva replacement products and
mouth washes for the management of xerostomia often based on familiarity and ad-hoc
experience rather than guidelines or evidence
bull Last year I organised with Dr Conn Haughey for all of MDT to try a large selection of
mouthcare products and contrasted our current clinical practice before trying the products
and after (approx 60 different health care professionals tried the products)
Before and After Top 5 amp Top 3 Top 5 rankings
before Top 5 rankings
after Top 3 rankings
before Top 3 rankings
after
Oral balance (Biotene) gel (47)
Biotene moisturising
mouthwash (36)
Oral balance (Biotene) gel (33)
Biotene moisturising
mouthwash (29)
Biotene moisturising
mouthwash (35)
Sugar free chewing gum (35)
Biotene moisturising
mouthwash (30)
Sugar free chewing gum (21)
Glandosane (natural) spray (34)
Salivix sugar free pastilles (30)
Glandosane (natural) spray (16)
Oral balance (Biotene) gelSips of water (1616)
Sugar free chewing gum (24)
Oral balance (Biotene) gelSips of water (2525)
Sips of water (13) Salivix sugar free pastilles (13)
Sips of water (21) Sugar free chewing gum (9)
0
3
5
8
10
13
COB MG RM KS DF GS EH SM EM MG MP AM FH
overall dryness score
overall dryness score
patient
overall dryness score
COB 0
MG 4
RM 4
KS 5
DF 5
GS 5
EH 6
SM 6
EM 8
MG 8
MP 9
AM 9
FH 10
Mean 62
0 ndash not dry - normal 10 ndash as dry as can be
29515 and 2615
Removed 4 patients 2 could not respond 1 inappropriate 1 confused
13
Mouthcare Pre
Patient Biotene Nystatin Salivex other
COB 0 0 0 0
MG 0 0 0 0
RM 0 1 0 0
KS 1 0 0 chewing gum
DF 1 0 1 0
GS 0 0 0 0
EH 1 0 1 Daktarin
SM 1 1 1 0
EM 1 1 0 0
MG 0 0 0 0
MP 0 0 0 0
AM 1 1 1 0
FH 1 0 1 occasional
lollies
7 4 5
Most had no product
It became clear a local guideline needed to be constructed to consolidate this new information and create consistency across our practice in Northern Ireland Bedford Cambridge Shrewsbury I searched and collated other sources of information and guidelines on Xereostomia includinghellip 1) PCF5 (p599) 2) Dental and Oral Care chart (RVH) 3) Dental and Oral Hygiene Chart (Dental School) 4) Marie Curie Oral Assessment tool 5) Oxford handbook on Palliative Care 6) PANG guidelines (p64) 7) uptodate website 8) European Essential Palliative Care certificate 9) Belfast Dental School 10)Bedford Mouthcare protocol
11) Addenbrooks - Good oral care 12) BMJ ndash oral care
16
Failed flow diagram
It also became evident there was huge overlap between xerostomia and other aspects of mouth care in particular including management of Thrush management of painful mouth and Denture care These aspects where all inseparable Issues raised and noted 1) Difficulty diagnosis of thrush ( coating) 2) Denture care (using toothbrushes masking thrushulcers) 3) Vaseline - not with oxygen 4) Brushing teeth once day 5) Unclear guidelines on painful mouth
The guideline clearly also had to incorporate and clarify these aspects
This myth is based on the National Fire Protection Associations (NFPA) 1996 edition of its Standard for Health Care Facilities which states Oil grease or other flammable contaminants shall not be used with oxygen equipment (item 8-6222) and Flammable and combustible liquids shall not be permitted within the site of intentional expulsion (item 8-6223) There is no evidence of any danger
Petroleum Jelly and Oxygen
1) Winslow EH Jacobson AF Dispelling the petroleum jelly myth AM J
Nurs199898(11)16)
2) Phippen ML Is petroleum jelly safe AM J Nurs 1999 99(8)24
3) Woodrow P Petroleum jelly myth Nurs Older People 2004 16(6) 41
Are there any adverse incidents reported in the literature There are NO case reports of adverse incidents with Vaseline applied to lips
1) Ocak I1 Raffensperger J Turkbey B Fuhrman C Lipid pneumonia secondary to
Petroleum jelly use in a patient with tympanic membrane perforation JBR-BTR
2009 Nov-Dec92(6)280-2
2) Gorospe L1 Gallego-Rivera JI Hervaacutes-Moroacuten A Exogenous lipoid pneumonia
secondary to Petroleum jelly application to the tracheostomy in a laryngectomy
patient PETCT and MR imaging findings Clin Imaging 2013 Jan-Feb37(1)163-
6 doi 101016jclinimag201202002 Epub 2012 Jun 8
Is there a fire risk
There have been some reports of surgical ignitions of
various materials such as Chlorhexidine and
Tracheostomy plastic These took place in a surgical
setting with high concentrations of oxygen and with a
clear ignition source most commonly diathermy
cauterization
NOT Vaseline
1) Gorphe P1 Sarfati B2 Janot F2 Bourgain JL3 Motamed C3 Blot F3
Temam S2 Airway fire during tracheostomy Eur Ann Otorhinolaryngol
Head Neck Dis 2014 Jun131(3)197-9 doi
101016janorl201307001 Epub 2014 Apr 1
2) Bengezi O2 Third-degree burns caused by ignition of chlorhexidine A
case report and systematic review of the literature Plast Surg (Oakv)
2014 Winter22(4)264-6 Vo A1
The Material Safety Data Sheets by Sasol demonstrate the flash
point of petroleum jelly to be around 150 degrees Celsius and an
autoignition temperature of around 320 degrees Celsius
This is way above normal environmental encounters and consistent
with plastics considered very safe
(For example Polyvinyl chloride (PVC) Flash point 250 degrees and
Ignition temp 450 degrees)
1) Sasol Material Safety Data Sheet ndash Petroleum Jelly Revision date
1142011 Created by BShamase approved by Ephraim Papo
Vaseline is flammable right
httpswwwyoutubecomwatchv=8hAUKTnHlcg
Petroleum jelly without oxygen - blow torch
httpswwwyoutubecomwatchv=yLqixjvTD7s
Petroleum jelly mixed with oxygen - blow torch
httpswwwyoutubecomwatchv=asumR-n2e6k
Oxygen Tubing
Ignition with lighter Ignition with blow torch
Petroleum jelly on
it own
Melted never ignited Melted 120 seconds to
ignite
Petroleum jelly
mixed with oxygen
10min (high flow)
Melted never ignited Melted 111 second to
ignite
Cotton wool on its
own
Ignition 3 seconds burn
time 45 seconds
Ignition instant burn time
40 seconds
Cotton wool mixed
with petroleum jelly
Ignition 11 seconds
burn time 197 seconds
Ignition instant burn time
113 seconds
Oxygen tubing Ignition 18 seconds
burn time 10 seconds
Ignition instant burn time
8 seconds
In gathering the opinions of 52 carers and nursing colleagues in
Bedford Hospital Addenbrooks and Sue Ryder Hospice in relation
to the use of petroleum Jelly with oxygen the following concerns
were highlighted
1) Risk of blame if anything untoward happens
2) Potential to be told off by seniors
3) Must not challenge policy even if I personally disagree
4) The change would not be sustained by my colleagues
A lot of resistancehellip Why
There is no evidence that Vaseline is superior to aqueous products at maintaining moisture in the mouth Howeverhellip In my expereince (and I would argue the vast majority of carers and nurses) would use vaseline for themselves and think its superior to aquos products What do you think
28
Brushing teeth
1 Hale KJ American Academy of Pediatrics Section on Pediatric
Dentistry Oral health risk assessment timing and establishment
of the dental home Pediatrics 2003 1111113
2 Beltraacuten-Aguilar ED Barker LK Canto MT et al Surveillance for
dental caries dental sealants tooth retention edentulism and
enamel fluorosis--United States 1988-1994 and 1999-2002
MMWR Surveill Summ 2005 541
3 NIDR the prevalence of dental caries in United States children
The National Caries Prevalence Survey 1979-1989 NIH
Publication 82-2245 National Instutute of Dental Research
National Caries Program 1981
4 Brunelle JA Oral health of United States children The National
Survey of Dental Caries in US School Children 1986-1987 NIH
Publication 9-2247 National Institute of Dental Research
Epidemiology and Disease Prevention Program 1989
5 Kelly JE Harvey CR Basic data on dental examination findings
of persons 1-74 years United States 1971-1974 Vital Health
Stat 11 1979 1
There is clear consensus throughout dental literature regarding the importance of regular brushing with a fluoride toothpaste - generally recommending after every meal
Are we brushing teeth NI Hospice I was assured we were brushing teeth at least twice day So I measured ithellip A single night 7 out of the 13 patients got their teeth brushed twicendash NI hospice St Johns Hospice Sue Ryder That would never happen to us we definitely do it twice day So I measured ithellip 13 out of 20 patients got their teeth brushed twice - St Johns Hospice Severn Hospice Community Of also interesting note do not rinse your mouth afterwards to allow fluoride to act
Non foaming toothpaste
Sodium laureth sulfate (SLS) or sodium lauryl ether sulfate (SLES) is a detergent and surfactant found in many personal care products (soaps shampoos toothpastes etc) bull It makes the toothpaste froth
bull SLS Free toothpastes are available
bull Make sure they are fluoride based
bull Less drying than normal toothpaste
bull Take a while to get used to
31
Denture Care
bull A huge area and confusing
bull A lot of different products and makes
bull Dependent upon what the denture is made of ie type of plastic and if contains metal or ceramic or not
bull All do come with their own recommendations
bull Recommend taking dentures out and soaking overnight withhellip
bull Chlorhexadine 02 MW is safe with all (however risks staining the teeth pink) bull Steradent is also very safe as a cleaning agent
bull Toothpaste (with or without fluoride) is corroding and dentures should not be
brushed with this rather use soap and water and rinse well
bull If remaining teeth they should be brushed as normal with fluoride toothpaste
bull Dentures should be taken out at night unless strong patient preference to leave in
32
Painful mouth
I collated a local guideline on the evidence available from the sources mentioned earlier and then expert opinion from my colleagues as to the order and preferences
bull Is it mucositis (Recent chemo or radiotherapy)
bull Recommendations of a baby (soft) toothbrushes to examine a mouth and clean a mucky mouth
bull Some evidence for Benzydamine Hydrochloride 015 oral rinse (Difflam) 10-15ml rinsegargle for 20-30sec QDS Benzydamine Hydrochloride Oromucosal spray 015 QDS
bull Most common problem is battling onhellip If treatment stings stop and re-assess
bull Many other options
Thrush
It is very difficult on occasion to differentiate between a coated mouth and thrush A couple of possible useful differentiating factors (although none are certain) - open for discussion 1) plaques on softhard palate (anywhere but tongue) - more likely thrush 2) Isolated on tongue - less likely thrush 3) plaques easily cleaned away with soft toothbrush - less likely thrush 4) mucky plaques - less likely thrush With all considerations made and there could be duel pathology consider a trail of treatment in conjunction with good oral hygiene care
35
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had had an input
Re audited the ward on the 17th June
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
What is a Quality improvement project An audit has the audit cycle to measure what we do against defined standards Not everything has standards defined has unclear or no guidelines Some of these things would improve quality of patient and staff with general common sense A QI projects allows incremental and measurable changes to make a difference to patientsrsquo care bull More flexible and dynamic
bull if something does not work to scrap it
bull employs multiple changes
Dry Mouth (aka Xerostomia)
Highly prevalent symptom in palliative care
Incidence of 60-80 in patients with advanced cancer (PANG 2011)
Risk factors includehellip
1) Medications
2) Mouth breathing
3) Advanced age
4) Previous history of radiation to the head and neck
5) Sjoumlgrenrsquos syndrome (the SICCA syndromes)
6) Diabetes mellitus (or vascular diseases)
7) Anxiety states 8) Dehydration
Medications seem to be the significant cause of Xerostomia in palliative carerdquo - (1)
ldquoA median number of four drugs they were associated with xerostomia - (2)
ldquoDry mouth can alter taste and make it difficult for patients to eat and swallow and
may also complain of mouth pain and difficulty with speakingrdquo ndash (2)
- Swallow tablets eat drink effectively
1) Davies AN Broadley K Beighton D Xerostomia in patients with advanced cancer J Pain Symptom Manage 2001 22820
2) Sweeney MP Bagg J The mouth and palliative care Am J Hosp Palliat Care 2000 17118
Medications
bull Xerostomia is a significant problem for many palliative patients with an incidence
of 60-80 in patients with advanced cancer and those being admitted to hospice units
(PANG guidelines 2011)
bull NICE highlights that when managing xerostomia in a palliative population individual
patient preference is likely to influence product acceptability and compliance (NICE
2012 Palliative Cancer Care - Oral)
bull A Cochrane review on the interventions for management of dry mouth (which was not
specific to the palliative care population) did not identify any strong evidence that any
topical therapy is effective for relieving the symptoms of dry mouth (Furness S et al
2011)
bull There are to date no randomised controlled trials demonstrating a superiority of any
individual mouth care products or oral saliva replacement products to each other in a
palliative population
bull Systematic literature review Xerostomia in advanced cancer patients (Supportive Care
in Cancer vol 23(3) Oct 2014)
bull The aim of this review was to determine the effectiveness of pharmacological and non-
pharmacological interventions in treating xerostomia in adult advanced cancer patients
Literature Search
bull Results
ndash 3 RCTs and 3 prospective studies
ndash Compared acupuncture pilocarpine Saliva Orthana and chewing gum with placebo
ndash All interventions were considered effective in treating xerostomia to equal effect
ndash However effectiveness versus placebo often could not be demonstrated statistically significantly
ndash No meta analysis possible ndash too small
bull Conclusion
ndash Limited published data exists so no firm conclusions can be drawn
ndash However pilocarpine artificial saliva chewing gum and acupuncture have some evidence
ndash This highlights the explicit need to improve our evidence base Properly constructed RCTs are
required
bull Systematic literature review Xerostomia in advanced cancer patients (Supportive Care in
Cancer vol 23(3) Oct 2014)
bull Palliative Medicine as a whole recommend a variety of oral saliva replacement products and
mouth washes for the management of xerostomia often based on familiarity and ad-hoc
experience rather than guidelines or evidence
bull Last year I organised with Dr Conn Haughey for all of MDT to try a large selection of
mouthcare products and contrasted our current clinical practice before trying the products
and after (approx 60 different health care professionals tried the products)
Before and After Top 5 amp Top 3 Top 5 rankings
before Top 5 rankings
after Top 3 rankings
before Top 3 rankings
after
Oral balance (Biotene) gel (47)
Biotene moisturising
mouthwash (36)
Oral balance (Biotene) gel (33)
Biotene moisturising
mouthwash (29)
Biotene moisturising
mouthwash (35)
Sugar free chewing gum (35)
Biotene moisturising
mouthwash (30)
Sugar free chewing gum (21)
Glandosane (natural) spray (34)
Salivix sugar free pastilles (30)
Glandosane (natural) spray (16)
Oral balance (Biotene) gelSips of water (1616)
Sugar free chewing gum (24)
Oral balance (Biotene) gelSips of water (2525)
Sips of water (13) Salivix sugar free pastilles (13)
Sips of water (21) Sugar free chewing gum (9)
0
3
5
8
10
13
COB MG RM KS DF GS EH SM EM MG MP AM FH
overall dryness score
overall dryness score
patient
overall dryness score
COB 0
MG 4
RM 4
KS 5
DF 5
GS 5
EH 6
SM 6
EM 8
MG 8
MP 9
AM 9
FH 10
Mean 62
0 ndash not dry - normal 10 ndash as dry as can be
29515 and 2615
Removed 4 patients 2 could not respond 1 inappropriate 1 confused
13
Mouthcare Pre
Patient Biotene Nystatin Salivex other
COB 0 0 0 0
MG 0 0 0 0
RM 0 1 0 0
KS 1 0 0 chewing gum
DF 1 0 1 0
GS 0 0 0 0
EH 1 0 1 Daktarin
SM 1 1 1 0
EM 1 1 0 0
MG 0 0 0 0
MP 0 0 0 0
AM 1 1 1 0
FH 1 0 1 occasional
lollies
7 4 5
Most had no product
It became clear a local guideline needed to be constructed to consolidate this new information and create consistency across our practice in Northern Ireland Bedford Cambridge Shrewsbury I searched and collated other sources of information and guidelines on Xereostomia includinghellip 1) PCF5 (p599) 2) Dental and Oral Care chart (RVH) 3) Dental and Oral Hygiene Chart (Dental School) 4) Marie Curie Oral Assessment tool 5) Oxford handbook on Palliative Care 6) PANG guidelines (p64) 7) uptodate website 8) European Essential Palliative Care certificate 9) Belfast Dental School 10)Bedford Mouthcare protocol
11) Addenbrooks - Good oral care 12) BMJ ndash oral care
16
Failed flow diagram
It also became evident there was huge overlap between xerostomia and other aspects of mouth care in particular including management of Thrush management of painful mouth and Denture care These aspects where all inseparable Issues raised and noted 1) Difficulty diagnosis of thrush ( coating) 2) Denture care (using toothbrushes masking thrushulcers) 3) Vaseline - not with oxygen 4) Brushing teeth once day 5) Unclear guidelines on painful mouth
The guideline clearly also had to incorporate and clarify these aspects
This myth is based on the National Fire Protection Associations (NFPA) 1996 edition of its Standard for Health Care Facilities which states Oil grease or other flammable contaminants shall not be used with oxygen equipment (item 8-6222) and Flammable and combustible liquids shall not be permitted within the site of intentional expulsion (item 8-6223) There is no evidence of any danger
Petroleum Jelly and Oxygen
1) Winslow EH Jacobson AF Dispelling the petroleum jelly myth AM J
Nurs199898(11)16)
2) Phippen ML Is petroleum jelly safe AM J Nurs 1999 99(8)24
3) Woodrow P Petroleum jelly myth Nurs Older People 2004 16(6) 41
Are there any adverse incidents reported in the literature There are NO case reports of adverse incidents with Vaseline applied to lips
1) Ocak I1 Raffensperger J Turkbey B Fuhrman C Lipid pneumonia secondary to
Petroleum jelly use in a patient with tympanic membrane perforation JBR-BTR
2009 Nov-Dec92(6)280-2
2) Gorospe L1 Gallego-Rivera JI Hervaacutes-Moroacuten A Exogenous lipoid pneumonia
secondary to Petroleum jelly application to the tracheostomy in a laryngectomy
patient PETCT and MR imaging findings Clin Imaging 2013 Jan-Feb37(1)163-
6 doi 101016jclinimag201202002 Epub 2012 Jun 8
Is there a fire risk
There have been some reports of surgical ignitions of
various materials such as Chlorhexidine and
Tracheostomy plastic These took place in a surgical
setting with high concentrations of oxygen and with a
clear ignition source most commonly diathermy
cauterization
NOT Vaseline
1) Gorphe P1 Sarfati B2 Janot F2 Bourgain JL3 Motamed C3 Blot F3
Temam S2 Airway fire during tracheostomy Eur Ann Otorhinolaryngol
Head Neck Dis 2014 Jun131(3)197-9 doi
101016janorl201307001 Epub 2014 Apr 1
2) Bengezi O2 Third-degree burns caused by ignition of chlorhexidine A
case report and systematic review of the literature Plast Surg (Oakv)
2014 Winter22(4)264-6 Vo A1
The Material Safety Data Sheets by Sasol demonstrate the flash
point of petroleum jelly to be around 150 degrees Celsius and an
autoignition temperature of around 320 degrees Celsius
This is way above normal environmental encounters and consistent
with plastics considered very safe
(For example Polyvinyl chloride (PVC) Flash point 250 degrees and
Ignition temp 450 degrees)
1) Sasol Material Safety Data Sheet ndash Petroleum Jelly Revision date
1142011 Created by BShamase approved by Ephraim Papo
Vaseline is flammable right
httpswwwyoutubecomwatchv=8hAUKTnHlcg
Petroleum jelly without oxygen - blow torch
httpswwwyoutubecomwatchv=yLqixjvTD7s
Petroleum jelly mixed with oxygen - blow torch
httpswwwyoutubecomwatchv=asumR-n2e6k
Oxygen Tubing
Ignition with lighter Ignition with blow torch
Petroleum jelly on
it own
Melted never ignited Melted 120 seconds to
ignite
Petroleum jelly
mixed with oxygen
10min (high flow)
Melted never ignited Melted 111 second to
ignite
Cotton wool on its
own
Ignition 3 seconds burn
time 45 seconds
Ignition instant burn time
40 seconds
Cotton wool mixed
with petroleum jelly
Ignition 11 seconds
burn time 197 seconds
Ignition instant burn time
113 seconds
Oxygen tubing Ignition 18 seconds
burn time 10 seconds
Ignition instant burn time
8 seconds
In gathering the opinions of 52 carers and nursing colleagues in
Bedford Hospital Addenbrooks and Sue Ryder Hospice in relation
to the use of petroleum Jelly with oxygen the following concerns
were highlighted
1) Risk of blame if anything untoward happens
2) Potential to be told off by seniors
3) Must not challenge policy even if I personally disagree
4) The change would not be sustained by my colleagues
A lot of resistancehellip Why
There is no evidence that Vaseline is superior to aqueous products at maintaining moisture in the mouth Howeverhellip In my expereince (and I would argue the vast majority of carers and nurses) would use vaseline for themselves and think its superior to aquos products What do you think
28
Brushing teeth
1 Hale KJ American Academy of Pediatrics Section on Pediatric
Dentistry Oral health risk assessment timing and establishment
of the dental home Pediatrics 2003 1111113
2 Beltraacuten-Aguilar ED Barker LK Canto MT et al Surveillance for
dental caries dental sealants tooth retention edentulism and
enamel fluorosis--United States 1988-1994 and 1999-2002
MMWR Surveill Summ 2005 541
3 NIDR the prevalence of dental caries in United States children
The National Caries Prevalence Survey 1979-1989 NIH
Publication 82-2245 National Instutute of Dental Research
National Caries Program 1981
4 Brunelle JA Oral health of United States children The National
Survey of Dental Caries in US School Children 1986-1987 NIH
Publication 9-2247 National Institute of Dental Research
Epidemiology and Disease Prevention Program 1989
5 Kelly JE Harvey CR Basic data on dental examination findings
of persons 1-74 years United States 1971-1974 Vital Health
Stat 11 1979 1
There is clear consensus throughout dental literature regarding the importance of regular brushing with a fluoride toothpaste - generally recommending after every meal
Are we brushing teeth NI Hospice I was assured we were brushing teeth at least twice day So I measured ithellip A single night 7 out of the 13 patients got their teeth brushed twicendash NI hospice St Johns Hospice Sue Ryder That would never happen to us we definitely do it twice day So I measured ithellip 13 out of 20 patients got their teeth brushed twice - St Johns Hospice Severn Hospice Community Of also interesting note do not rinse your mouth afterwards to allow fluoride to act
Non foaming toothpaste
Sodium laureth sulfate (SLS) or sodium lauryl ether sulfate (SLES) is a detergent and surfactant found in many personal care products (soaps shampoos toothpastes etc) bull It makes the toothpaste froth
bull SLS Free toothpastes are available
bull Make sure they are fluoride based
bull Less drying than normal toothpaste
bull Take a while to get used to
31
Denture Care
bull A huge area and confusing
bull A lot of different products and makes
bull Dependent upon what the denture is made of ie type of plastic and if contains metal or ceramic or not
bull All do come with their own recommendations
bull Recommend taking dentures out and soaking overnight withhellip
bull Chlorhexadine 02 MW is safe with all (however risks staining the teeth pink) bull Steradent is also very safe as a cleaning agent
bull Toothpaste (with or without fluoride) is corroding and dentures should not be
brushed with this rather use soap and water and rinse well
bull If remaining teeth they should be brushed as normal with fluoride toothpaste
bull Dentures should be taken out at night unless strong patient preference to leave in
32
Painful mouth
I collated a local guideline on the evidence available from the sources mentioned earlier and then expert opinion from my colleagues as to the order and preferences
bull Is it mucositis (Recent chemo or radiotherapy)
bull Recommendations of a baby (soft) toothbrushes to examine a mouth and clean a mucky mouth
bull Some evidence for Benzydamine Hydrochloride 015 oral rinse (Difflam) 10-15ml rinsegargle for 20-30sec QDS Benzydamine Hydrochloride Oromucosal spray 015 QDS
bull Most common problem is battling onhellip If treatment stings stop and re-assess
bull Many other options
Thrush
It is very difficult on occasion to differentiate between a coated mouth and thrush A couple of possible useful differentiating factors (although none are certain) - open for discussion 1) plaques on softhard palate (anywhere but tongue) - more likely thrush 2) Isolated on tongue - less likely thrush 3) plaques easily cleaned away with soft toothbrush - less likely thrush 4) mucky plaques - less likely thrush With all considerations made and there could be duel pathology consider a trail of treatment in conjunction with good oral hygiene care
35
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had had an input
Re audited the ward on the 17th June
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
Dry Mouth (aka Xerostomia)
Highly prevalent symptom in palliative care
Incidence of 60-80 in patients with advanced cancer (PANG 2011)
Risk factors includehellip
1) Medications
2) Mouth breathing
3) Advanced age
4) Previous history of radiation to the head and neck
5) Sjoumlgrenrsquos syndrome (the SICCA syndromes)
6) Diabetes mellitus (or vascular diseases)
7) Anxiety states 8) Dehydration
Medications seem to be the significant cause of Xerostomia in palliative carerdquo - (1)
ldquoA median number of four drugs they were associated with xerostomia - (2)
ldquoDry mouth can alter taste and make it difficult for patients to eat and swallow and
may also complain of mouth pain and difficulty with speakingrdquo ndash (2)
- Swallow tablets eat drink effectively
1) Davies AN Broadley K Beighton D Xerostomia in patients with advanced cancer J Pain Symptom Manage 2001 22820
2) Sweeney MP Bagg J The mouth and palliative care Am J Hosp Palliat Care 2000 17118
Medications
bull Xerostomia is a significant problem for many palliative patients with an incidence
of 60-80 in patients with advanced cancer and those being admitted to hospice units
(PANG guidelines 2011)
bull NICE highlights that when managing xerostomia in a palliative population individual
patient preference is likely to influence product acceptability and compliance (NICE
2012 Palliative Cancer Care - Oral)
bull A Cochrane review on the interventions for management of dry mouth (which was not
specific to the palliative care population) did not identify any strong evidence that any
topical therapy is effective for relieving the symptoms of dry mouth (Furness S et al
2011)
bull There are to date no randomised controlled trials demonstrating a superiority of any
individual mouth care products or oral saliva replacement products to each other in a
palliative population
bull Systematic literature review Xerostomia in advanced cancer patients (Supportive Care
in Cancer vol 23(3) Oct 2014)
bull The aim of this review was to determine the effectiveness of pharmacological and non-
pharmacological interventions in treating xerostomia in adult advanced cancer patients
Literature Search
bull Results
ndash 3 RCTs and 3 prospective studies
ndash Compared acupuncture pilocarpine Saliva Orthana and chewing gum with placebo
ndash All interventions were considered effective in treating xerostomia to equal effect
ndash However effectiveness versus placebo often could not be demonstrated statistically significantly
ndash No meta analysis possible ndash too small
bull Conclusion
ndash Limited published data exists so no firm conclusions can be drawn
ndash However pilocarpine artificial saliva chewing gum and acupuncture have some evidence
ndash This highlights the explicit need to improve our evidence base Properly constructed RCTs are
required
bull Systematic literature review Xerostomia in advanced cancer patients (Supportive Care in
Cancer vol 23(3) Oct 2014)
bull Palliative Medicine as a whole recommend a variety of oral saliva replacement products and
mouth washes for the management of xerostomia often based on familiarity and ad-hoc
experience rather than guidelines or evidence
bull Last year I organised with Dr Conn Haughey for all of MDT to try a large selection of
mouthcare products and contrasted our current clinical practice before trying the products
and after (approx 60 different health care professionals tried the products)
Before and After Top 5 amp Top 3 Top 5 rankings
before Top 5 rankings
after Top 3 rankings
before Top 3 rankings
after
Oral balance (Biotene) gel (47)
Biotene moisturising
mouthwash (36)
Oral balance (Biotene) gel (33)
Biotene moisturising
mouthwash (29)
Biotene moisturising
mouthwash (35)
Sugar free chewing gum (35)
Biotene moisturising
mouthwash (30)
Sugar free chewing gum (21)
Glandosane (natural) spray (34)
Salivix sugar free pastilles (30)
Glandosane (natural) spray (16)
Oral balance (Biotene) gelSips of water (1616)
Sugar free chewing gum (24)
Oral balance (Biotene) gelSips of water (2525)
Sips of water (13) Salivix sugar free pastilles (13)
Sips of water (21) Sugar free chewing gum (9)
0
3
5
8
10
13
COB MG RM KS DF GS EH SM EM MG MP AM FH
overall dryness score
overall dryness score
patient
overall dryness score
COB 0
MG 4
RM 4
KS 5
DF 5
GS 5
EH 6
SM 6
EM 8
MG 8
MP 9
AM 9
FH 10
Mean 62
0 ndash not dry - normal 10 ndash as dry as can be
29515 and 2615
Removed 4 patients 2 could not respond 1 inappropriate 1 confused
13
Mouthcare Pre
Patient Biotene Nystatin Salivex other
COB 0 0 0 0
MG 0 0 0 0
RM 0 1 0 0
KS 1 0 0 chewing gum
DF 1 0 1 0
GS 0 0 0 0
EH 1 0 1 Daktarin
SM 1 1 1 0
EM 1 1 0 0
MG 0 0 0 0
MP 0 0 0 0
AM 1 1 1 0
FH 1 0 1 occasional
lollies
7 4 5
Most had no product
It became clear a local guideline needed to be constructed to consolidate this new information and create consistency across our practice in Northern Ireland Bedford Cambridge Shrewsbury I searched and collated other sources of information and guidelines on Xereostomia includinghellip 1) PCF5 (p599) 2) Dental and Oral Care chart (RVH) 3) Dental and Oral Hygiene Chart (Dental School) 4) Marie Curie Oral Assessment tool 5) Oxford handbook on Palliative Care 6) PANG guidelines (p64) 7) uptodate website 8) European Essential Palliative Care certificate 9) Belfast Dental School 10)Bedford Mouthcare protocol
11) Addenbrooks - Good oral care 12) BMJ ndash oral care
16
Failed flow diagram
It also became evident there was huge overlap between xerostomia and other aspects of mouth care in particular including management of Thrush management of painful mouth and Denture care These aspects where all inseparable Issues raised and noted 1) Difficulty diagnosis of thrush ( coating) 2) Denture care (using toothbrushes masking thrushulcers) 3) Vaseline - not with oxygen 4) Brushing teeth once day 5) Unclear guidelines on painful mouth
The guideline clearly also had to incorporate and clarify these aspects
This myth is based on the National Fire Protection Associations (NFPA) 1996 edition of its Standard for Health Care Facilities which states Oil grease or other flammable contaminants shall not be used with oxygen equipment (item 8-6222) and Flammable and combustible liquids shall not be permitted within the site of intentional expulsion (item 8-6223) There is no evidence of any danger
Petroleum Jelly and Oxygen
1) Winslow EH Jacobson AF Dispelling the petroleum jelly myth AM J
Nurs199898(11)16)
2) Phippen ML Is petroleum jelly safe AM J Nurs 1999 99(8)24
3) Woodrow P Petroleum jelly myth Nurs Older People 2004 16(6) 41
Are there any adverse incidents reported in the literature There are NO case reports of adverse incidents with Vaseline applied to lips
1) Ocak I1 Raffensperger J Turkbey B Fuhrman C Lipid pneumonia secondary to
Petroleum jelly use in a patient with tympanic membrane perforation JBR-BTR
2009 Nov-Dec92(6)280-2
2) Gorospe L1 Gallego-Rivera JI Hervaacutes-Moroacuten A Exogenous lipoid pneumonia
secondary to Petroleum jelly application to the tracheostomy in a laryngectomy
patient PETCT and MR imaging findings Clin Imaging 2013 Jan-Feb37(1)163-
6 doi 101016jclinimag201202002 Epub 2012 Jun 8
Is there a fire risk
There have been some reports of surgical ignitions of
various materials such as Chlorhexidine and
Tracheostomy plastic These took place in a surgical
setting with high concentrations of oxygen and with a
clear ignition source most commonly diathermy
cauterization
NOT Vaseline
1) Gorphe P1 Sarfati B2 Janot F2 Bourgain JL3 Motamed C3 Blot F3
Temam S2 Airway fire during tracheostomy Eur Ann Otorhinolaryngol
Head Neck Dis 2014 Jun131(3)197-9 doi
101016janorl201307001 Epub 2014 Apr 1
2) Bengezi O2 Third-degree burns caused by ignition of chlorhexidine A
case report and systematic review of the literature Plast Surg (Oakv)
2014 Winter22(4)264-6 Vo A1
The Material Safety Data Sheets by Sasol demonstrate the flash
point of petroleum jelly to be around 150 degrees Celsius and an
autoignition temperature of around 320 degrees Celsius
This is way above normal environmental encounters and consistent
with plastics considered very safe
(For example Polyvinyl chloride (PVC) Flash point 250 degrees and
Ignition temp 450 degrees)
1) Sasol Material Safety Data Sheet ndash Petroleum Jelly Revision date
1142011 Created by BShamase approved by Ephraim Papo
Vaseline is flammable right
httpswwwyoutubecomwatchv=8hAUKTnHlcg
Petroleum jelly without oxygen - blow torch
httpswwwyoutubecomwatchv=yLqixjvTD7s
Petroleum jelly mixed with oxygen - blow torch
httpswwwyoutubecomwatchv=asumR-n2e6k
Oxygen Tubing
Ignition with lighter Ignition with blow torch
Petroleum jelly on
it own
Melted never ignited Melted 120 seconds to
ignite
Petroleum jelly
mixed with oxygen
10min (high flow)
Melted never ignited Melted 111 second to
ignite
Cotton wool on its
own
Ignition 3 seconds burn
time 45 seconds
Ignition instant burn time
40 seconds
Cotton wool mixed
with petroleum jelly
Ignition 11 seconds
burn time 197 seconds
Ignition instant burn time
113 seconds
Oxygen tubing Ignition 18 seconds
burn time 10 seconds
Ignition instant burn time
8 seconds
In gathering the opinions of 52 carers and nursing colleagues in
Bedford Hospital Addenbrooks and Sue Ryder Hospice in relation
to the use of petroleum Jelly with oxygen the following concerns
were highlighted
1) Risk of blame if anything untoward happens
2) Potential to be told off by seniors
3) Must not challenge policy even if I personally disagree
4) The change would not be sustained by my colleagues
A lot of resistancehellip Why
There is no evidence that Vaseline is superior to aqueous products at maintaining moisture in the mouth Howeverhellip In my expereince (and I would argue the vast majority of carers and nurses) would use vaseline for themselves and think its superior to aquos products What do you think
28
Brushing teeth
1 Hale KJ American Academy of Pediatrics Section on Pediatric
Dentistry Oral health risk assessment timing and establishment
of the dental home Pediatrics 2003 1111113
2 Beltraacuten-Aguilar ED Barker LK Canto MT et al Surveillance for
dental caries dental sealants tooth retention edentulism and
enamel fluorosis--United States 1988-1994 and 1999-2002
MMWR Surveill Summ 2005 541
3 NIDR the prevalence of dental caries in United States children
The National Caries Prevalence Survey 1979-1989 NIH
Publication 82-2245 National Instutute of Dental Research
National Caries Program 1981
4 Brunelle JA Oral health of United States children The National
Survey of Dental Caries in US School Children 1986-1987 NIH
Publication 9-2247 National Institute of Dental Research
Epidemiology and Disease Prevention Program 1989
5 Kelly JE Harvey CR Basic data on dental examination findings
of persons 1-74 years United States 1971-1974 Vital Health
Stat 11 1979 1
There is clear consensus throughout dental literature regarding the importance of regular brushing with a fluoride toothpaste - generally recommending after every meal
Are we brushing teeth NI Hospice I was assured we were brushing teeth at least twice day So I measured ithellip A single night 7 out of the 13 patients got their teeth brushed twicendash NI hospice St Johns Hospice Sue Ryder That would never happen to us we definitely do it twice day So I measured ithellip 13 out of 20 patients got their teeth brushed twice - St Johns Hospice Severn Hospice Community Of also interesting note do not rinse your mouth afterwards to allow fluoride to act
Non foaming toothpaste
Sodium laureth sulfate (SLS) or sodium lauryl ether sulfate (SLES) is a detergent and surfactant found in many personal care products (soaps shampoos toothpastes etc) bull It makes the toothpaste froth
bull SLS Free toothpastes are available
bull Make sure they are fluoride based
bull Less drying than normal toothpaste
bull Take a while to get used to
31
Denture Care
bull A huge area and confusing
bull A lot of different products and makes
bull Dependent upon what the denture is made of ie type of plastic and if contains metal or ceramic or not
bull All do come with their own recommendations
bull Recommend taking dentures out and soaking overnight withhellip
bull Chlorhexadine 02 MW is safe with all (however risks staining the teeth pink) bull Steradent is also very safe as a cleaning agent
bull Toothpaste (with or without fluoride) is corroding and dentures should not be
brushed with this rather use soap and water and rinse well
bull If remaining teeth they should be brushed as normal with fluoride toothpaste
bull Dentures should be taken out at night unless strong patient preference to leave in
32
Painful mouth
I collated a local guideline on the evidence available from the sources mentioned earlier and then expert opinion from my colleagues as to the order and preferences
bull Is it mucositis (Recent chemo or radiotherapy)
bull Recommendations of a baby (soft) toothbrushes to examine a mouth and clean a mucky mouth
bull Some evidence for Benzydamine Hydrochloride 015 oral rinse (Difflam) 10-15ml rinsegargle for 20-30sec QDS Benzydamine Hydrochloride Oromucosal spray 015 QDS
bull Most common problem is battling onhellip If treatment stings stop and re-assess
bull Many other options
Thrush
It is very difficult on occasion to differentiate between a coated mouth and thrush A couple of possible useful differentiating factors (although none are certain) - open for discussion 1) plaques on softhard palate (anywhere but tongue) - more likely thrush 2) Isolated on tongue - less likely thrush 3) plaques easily cleaned away with soft toothbrush - less likely thrush 4) mucky plaques - less likely thrush With all considerations made and there could be duel pathology consider a trail of treatment in conjunction with good oral hygiene care
35
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had had an input
Re audited the ward on the 17th June
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
Medications seem to be the significant cause of Xerostomia in palliative carerdquo - (1)
ldquoA median number of four drugs they were associated with xerostomia - (2)
ldquoDry mouth can alter taste and make it difficult for patients to eat and swallow and
may also complain of mouth pain and difficulty with speakingrdquo ndash (2)
- Swallow tablets eat drink effectively
1) Davies AN Broadley K Beighton D Xerostomia in patients with advanced cancer J Pain Symptom Manage 2001 22820
2) Sweeney MP Bagg J The mouth and palliative care Am J Hosp Palliat Care 2000 17118
Medications
bull Xerostomia is a significant problem for many palliative patients with an incidence
of 60-80 in patients with advanced cancer and those being admitted to hospice units
(PANG guidelines 2011)
bull NICE highlights that when managing xerostomia in a palliative population individual
patient preference is likely to influence product acceptability and compliance (NICE
2012 Palliative Cancer Care - Oral)
bull A Cochrane review on the interventions for management of dry mouth (which was not
specific to the palliative care population) did not identify any strong evidence that any
topical therapy is effective for relieving the symptoms of dry mouth (Furness S et al
2011)
bull There are to date no randomised controlled trials demonstrating a superiority of any
individual mouth care products or oral saliva replacement products to each other in a
palliative population
bull Systematic literature review Xerostomia in advanced cancer patients (Supportive Care
in Cancer vol 23(3) Oct 2014)
bull The aim of this review was to determine the effectiveness of pharmacological and non-
pharmacological interventions in treating xerostomia in adult advanced cancer patients
Literature Search
bull Results
ndash 3 RCTs and 3 prospective studies
ndash Compared acupuncture pilocarpine Saliva Orthana and chewing gum with placebo
ndash All interventions were considered effective in treating xerostomia to equal effect
ndash However effectiveness versus placebo often could not be demonstrated statistically significantly
ndash No meta analysis possible ndash too small
bull Conclusion
ndash Limited published data exists so no firm conclusions can be drawn
ndash However pilocarpine artificial saliva chewing gum and acupuncture have some evidence
ndash This highlights the explicit need to improve our evidence base Properly constructed RCTs are
required
bull Systematic literature review Xerostomia in advanced cancer patients (Supportive Care in
Cancer vol 23(3) Oct 2014)
bull Palliative Medicine as a whole recommend a variety of oral saliva replacement products and
mouth washes for the management of xerostomia often based on familiarity and ad-hoc
experience rather than guidelines or evidence
bull Last year I organised with Dr Conn Haughey for all of MDT to try a large selection of
mouthcare products and contrasted our current clinical practice before trying the products
and after (approx 60 different health care professionals tried the products)
Before and After Top 5 amp Top 3 Top 5 rankings
before Top 5 rankings
after Top 3 rankings
before Top 3 rankings
after
Oral balance (Biotene) gel (47)
Biotene moisturising
mouthwash (36)
Oral balance (Biotene) gel (33)
Biotene moisturising
mouthwash (29)
Biotene moisturising
mouthwash (35)
Sugar free chewing gum (35)
Biotene moisturising
mouthwash (30)
Sugar free chewing gum (21)
Glandosane (natural) spray (34)
Salivix sugar free pastilles (30)
Glandosane (natural) spray (16)
Oral balance (Biotene) gelSips of water (1616)
Sugar free chewing gum (24)
Oral balance (Biotene) gelSips of water (2525)
Sips of water (13) Salivix sugar free pastilles (13)
Sips of water (21) Sugar free chewing gum (9)
0
3
5
8
10
13
COB MG RM KS DF GS EH SM EM MG MP AM FH
overall dryness score
overall dryness score
patient
overall dryness score
COB 0
MG 4
RM 4
KS 5
DF 5
GS 5
EH 6
SM 6
EM 8
MG 8
MP 9
AM 9
FH 10
Mean 62
0 ndash not dry - normal 10 ndash as dry as can be
29515 and 2615
Removed 4 patients 2 could not respond 1 inappropriate 1 confused
13
Mouthcare Pre
Patient Biotene Nystatin Salivex other
COB 0 0 0 0
MG 0 0 0 0
RM 0 1 0 0
KS 1 0 0 chewing gum
DF 1 0 1 0
GS 0 0 0 0
EH 1 0 1 Daktarin
SM 1 1 1 0
EM 1 1 0 0
MG 0 0 0 0
MP 0 0 0 0
AM 1 1 1 0
FH 1 0 1 occasional
lollies
7 4 5
Most had no product
It became clear a local guideline needed to be constructed to consolidate this new information and create consistency across our practice in Northern Ireland Bedford Cambridge Shrewsbury I searched and collated other sources of information and guidelines on Xereostomia includinghellip 1) PCF5 (p599) 2) Dental and Oral Care chart (RVH) 3) Dental and Oral Hygiene Chart (Dental School) 4) Marie Curie Oral Assessment tool 5) Oxford handbook on Palliative Care 6) PANG guidelines (p64) 7) uptodate website 8) European Essential Palliative Care certificate 9) Belfast Dental School 10)Bedford Mouthcare protocol
11) Addenbrooks - Good oral care 12) BMJ ndash oral care
16
Failed flow diagram
It also became evident there was huge overlap between xerostomia and other aspects of mouth care in particular including management of Thrush management of painful mouth and Denture care These aspects where all inseparable Issues raised and noted 1) Difficulty diagnosis of thrush ( coating) 2) Denture care (using toothbrushes masking thrushulcers) 3) Vaseline - not with oxygen 4) Brushing teeth once day 5) Unclear guidelines on painful mouth
The guideline clearly also had to incorporate and clarify these aspects
This myth is based on the National Fire Protection Associations (NFPA) 1996 edition of its Standard for Health Care Facilities which states Oil grease or other flammable contaminants shall not be used with oxygen equipment (item 8-6222) and Flammable and combustible liquids shall not be permitted within the site of intentional expulsion (item 8-6223) There is no evidence of any danger
Petroleum Jelly and Oxygen
1) Winslow EH Jacobson AF Dispelling the petroleum jelly myth AM J
Nurs199898(11)16)
2) Phippen ML Is petroleum jelly safe AM J Nurs 1999 99(8)24
3) Woodrow P Petroleum jelly myth Nurs Older People 2004 16(6) 41
Are there any adverse incidents reported in the literature There are NO case reports of adverse incidents with Vaseline applied to lips
1) Ocak I1 Raffensperger J Turkbey B Fuhrman C Lipid pneumonia secondary to
Petroleum jelly use in a patient with tympanic membrane perforation JBR-BTR
2009 Nov-Dec92(6)280-2
2) Gorospe L1 Gallego-Rivera JI Hervaacutes-Moroacuten A Exogenous lipoid pneumonia
secondary to Petroleum jelly application to the tracheostomy in a laryngectomy
patient PETCT and MR imaging findings Clin Imaging 2013 Jan-Feb37(1)163-
6 doi 101016jclinimag201202002 Epub 2012 Jun 8
Is there a fire risk
There have been some reports of surgical ignitions of
various materials such as Chlorhexidine and
Tracheostomy plastic These took place in a surgical
setting with high concentrations of oxygen and with a
clear ignition source most commonly diathermy
cauterization
NOT Vaseline
1) Gorphe P1 Sarfati B2 Janot F2 Bourgain JL3 Motamed C3 Blot F3
Temam S2 Airway fire during tracheostomy Eur Ann Otorhinolaryngol
Head Neck Dis 2014 Jun131(3)197-9 doi
101016janorl201307001 Epub 2014 Apr 1
2) Bengezi O2 Third-degree burns caused by ignition of chlorhexidine A
case report and systematic review of the literature Plast Surg (Oakv)
2014 Winter22(4)264-6 Vo A1
The Material Safety Data Sheets by Sasol demonstrate the flash
point of petroleum jelly to be around 150 degrees Celsius and an
autoignition temperature of around 320 degrees Celsius
This is way above normal environmental encounters and consistent
with plastics considered very safe
(For example Polyvinyl chloride (PVC) Flash point 250 degrees and
Ignition temp 450 degrees)
1) Sasol Material Safety Data Sheet ndash Petroleum Jelly Revision date
1142011 Created by BShamase approved by Ephraim Papo
Vaseline is flammable right
httpswwwyoutubecomwatchv=8hAUKTnHlcg
Petroleum jelly without oxygen - blow torch
httpswwwyoutubecomwatchv=yLqixjvTD7s
Petroleum jelly mixed with oxygen - blow torch
httpswwwyoutubecomwatchv=asumR-n2e6k
Oxygen Tubing
Ignition with lighter Ignition with blow torch
Petroleum jelly on
it own
Melted never ignited Melted 120 seconds to
ignite
Petroleum jelly
mixed with oxygen
10min (high flow)
Melted never ignited Melted 111 second to
ignite
Cotton wool on its
own
Ignition 3 seconds burn
time 45 seconds
Ignition instant burn time
40 seconds
Cotton wool mixed
with petroleum jelly
Ignition 11 seconds
burn time 197 seconds
Ignition instant burn time
113 seconds
Oxygen tubing Ignition 18 seconds
burn time 10 seconds
Ignition instant burn time
8 seconds
In gathering the opinions of 52 carers and nursing colleagues in
Bedford Hospital Addenbrooks and Sue Ryder Hospice in relation
to the use of petroleum Jelly with oxygen the following concerns
were highlighted
1) Risk of blame if anything untoward happens
2) Potential to be told off by seniors
3) Must not challenge policy even if I personally disagree
4) The change would not be sustained by my colleagues
A lot of resistancehellip Why
There is no evidence that Vaseline is superior to aqueous products at maintaining moisture in the mouth Howeverhellip In my expereince (and I would argue the vast majority of carers and nurses) would use vaseline for themselves and think its superior to aquos products What do you think
28
Brushing teeth
1 Hale KJ American Academy of Pediatrics Section on Pediatric
Dentistry Oral health risk assessment timing and establishment
of the dental home Pediatrics 2003 1111113
2 Beltraacuten-Aguilar ED Barker LK Canto MT et al Surveillance for
dental caries dental sealants tooth retention edentulism and
enamel fluorosis--United States 1988-1994 and 1999-2002
MMWR Surveill Summ 2005 541
3 NIDR the prevalence of dental caries in United States children
The National Caries Prevalence Survey 1979-1989 NIH
Publication 82-2245 National Instutute of Dental Research
National Caries Program 1981
4 Brunelle JA Oral health of United States children The National
Survey of Dental Caries in US School Children 1986-1987 NIH
Publication 9-2247 National Institute of Dental Research
Epidemiology and Disease Prevention Program 1989
5 Kelly JE Harvey CR Basic data on dental examination findings
of persons 1-74 years United States 1971-1974 Vital Health
Stat 11 1979 1
There is clear consensus throughout dental literature regarding the importance of regular brushing with a fluoride toothpaste - generally recommending after every meal
Are we brushing teeth NI Hospice I was assured we were brushing teeth at least twice day So I measured ithellip A single night 7 out of the 13 patients got their teeth brushed twicendash NI hospice St Johns Hospice Sue Ryder That would never happen to us we definitely do it twice day So I measured ithellip 13 out of 20 patients got their teeth brushed twice - St Johns Hospice Severn Hospice Community Of also interesting note do not rinse your mouth afterwards to allow fluoride to act
Non foaming toothpaste
Sodium laureth sulfate (SLS) or sodium lauryl ether sulfate (SLES) is a detergent and surfactant found in many personal care products (soaps shampoos toothpastes etc) bull It makes the toothpaste froth
bull SLS Free toothpastes are available
bull Make sure they are fluoride based
bull Less drying than normal toothpaste
bull Take a while to get used to
31
Denture Care
bull A huge area and confusing
bull A lot of different products and makes
bull Dependent upon what the denture is made of ie type of plastic and if contains metal or ceramic or not
bull All do come with their own recommendations
bull Recommend taking dentures out and soaking overnight withhellip
bull Chlorhexadine 02 MW is safe with all (however risks staining the teeth pink) bull Steradent is also very safe as a cleaning agent
bull Toothpaste (with or without fluoride) is corroding and dentures should not be
brushed with this rather use soap and water and rinse well
bull If remaining teeth they should be brushed as normal with fluoride toothpaste
bull Dentures should be taken out at night unless strong patient preference to leave in
32
Painful mouth
I collated a local guideline on the evidence available from the sources mentioned earlier and then expert opinion from my colleagues as to the order and preferences
bull Is it mucositis (Recent chemo or radiotherapy)
bull Recommendations of a baby (soft) toothbrushes to examine a mouth and clean a mucky mouth
bull Some evidence for Benzydamine Hydrochloride 015 oral rinse (Difflam) 10-15ml rinsegargle for 20-30sec QDS Benzydamine Hydrochloride Oromucosal spray 015 QDS
bull Most common problem is battling onhellip If treatment stings stop and re-assess
bull Many other options
Thrush
It is very difficult on occasion to differentiate between a coated mouth and thrush A couple of possible useful differentiating factors (although none are certain) - open for discussion 1) plaques on softhard palate (anywhere but tongue) - more likely thrush 2) Isolated on tongue - less likely thrush 3) plaques easily cleaned away with soft toothbrush - less likely thrush 4) mucky plaques - less likely thrush With all considerations made and there could be duel pathology consider a trail of treatment in conjunction with good oral hygiene care
35
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had had an input
Re audited the ward on the 17th June
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
bull Xerostomia is a significant problem for many palliative patients with an incidence
of 60-80 in patients with advanced cancer and those being admitted to hospice units
(PANG guidelines 2011)
bull NICE highlights that when managing xerostomia in a palliative population individual
patient preference is likely to influence product acceptability and compliance (NICE
2012 Palliative Cancer Care - Oral)
bull A Cochrane review on the interventions for management of dry mouth (which was not
specific to the palliative care population) did not identify any strong evidence that any
topical therapy is effective for relieving the symptoms of dry mouth (Furness S et al
2011)
bull There are to date no randomised controlled trials demonstrating a superiority of any
individual mouth care products or oral saliva replacement products to each other in a
palliative population
bull Systematic literature review Xerostomia in advanced cancer patients (Supportive Care
in Cancer vol 23(3) Oct 2014)
bull The aim of this review was to determine the effectiveness of pharmacological and non-
pharmacological interventions in treating xerostomia in adult advanced cancer patients
Literature Search
bull Results
ndash 3 RCTs and 3 prospective studies
ndash Compared acupuncture pilocarpine Saliva Orthana and chewing gum with placebo
ndash All interventions were considered effective in treating xerostomia to equal effect
ndash However effectiveness versus placebo often could not be demonstrated statistically significantly
ndash No meta analysis possible ndash too small
bull Conclusion
ndash Limited published data exists so no firm conclusions can be drawn
ndash However pilocarpine artificial saliva chewing gum and acupuncture have some evidence
ndash This highlights the explicit need to improve our evidence base Properly constructed RCTs are
required
bull Systematic literature review Xerostomia in advanced cancer patients (Supportive Care in
Cancer vol 23(3) Oct 2014)
bull Palliative Medicine as a whole recommend a variety of oral saliva replacement products and
mouth washes for the management of xerostomia often based on familiarity and ad-hoc
experience rather than guidelines or evidence
bull Last year I organised with Dr Conn Haughey for all of MDT to try a large selection of
mouthcare products and contrasted our current clinical practice before trying the products
and after (approx 60 different health care professionals tried the products)
Before and After Top 5 amp Top 3 Top 5 rankings
before Top 5 rankings
after Top 3 rankings
before Top 3 rankings
after
Oral balance (Biotene) gel (47)
Biotene moisturising
mouthwash (36)
Oral balance (Biotene) gel (33)
Biotene moisturising
mouthwash (29)
Biotene moisturising
mouthwash (35)
Sugar free chewing gum (35)
Biotene moisturising
mouthwash (30)
Sugar free chewing gum (21)
Glandosane (natural) spray (34)
Salivix sugar free pastilles (30)
Glandosane (natural) spray (16)
Oral balance (Biotene) gelSips of water (1616)
Sugar free chewing gum (24)
Oral balance (Biotene) gelSips of water (2525)
Sips of water (13) Salivix sugar free pastilles (13)
Sips of water (21) Sugar free chewing gum (9)
0
3
5
8
10
13
COB MG RM KS DF GS EH SM EM MG MP AM FH
overall dryness score
overall dryness score
patient
overall dryness score
COB 0
MG 4
RM 4
KS 5
DF 5
GS 5
EH 6
SM 6
EM 8
MG 8
MP 9
AM 9
FH 10
Mean 62
0 ndash not dry - normal 10 ndash as dry as can be
29515 and 2615
Removed 4 patients 2 could not respond 1 inappropriate 1 confused
13
Mouthcare Pre
Patient Biotene Nystatin Salivex other
COB 0 0 0 0
MG 0 0 0 0
RM 0 1 0 0
KS 1 0 0 chewing gum
DF 1 0 1 0
GS 0 0 0 0
EH 1 0 1 Daktarin
SM 1 1 1 0
EM 1 1 0 0
MG 0 0 0 0
MP 0 0 0 0
AM 1 1 1 0
FH 1 0 1 occasional
lollies
7 4 5
Most had no product
It became clear a local guideline needed to be constructed to consolidate this new information and create consistency across our practice in Northern Ireland Bedford Cambridge Shrewsbury I searched and collated other sources of information and guidelines on Xereostomia includinghellip 1) PCF5 (p599) 2) Dental and Oral Care chart (RVH) 3) Dental and Oral Hygiene Chart (Dental School) 4) Marie Curie Oral Assessment tool 5) Oxford handbook on Palliative Care 6) PANG guidelines (p64) 7) uptodate website 8) European Essential Palliative Care certificate 9) Belfast Dental School 10)Bedford Mouthcare protocol
11) Addenbrooks - Good oral care 12) BMJ ndash oral care
16
Failed flow diagram
It also became evident there was huge overlap between xerostomia and other aspects of mouth care in particular including management of Thrush management of painful mouth and Denture care These aspects where all inseparable Issues raised and noted 1) Difficulty diagnosis of thrush ( coating) 2) Denture care (using toothbrushes masking thrushulcers) 3) Vaseline - not with oxygen 4) Brushing teeth once day 5) Unclear guidelines on painful mouth
The guideline clearly also had to incorporate and clarify these aspects
This myth is based on the National Fire Protection Associations (NFPA) 1996 edition of its Standard for Health Care Facilities which states Oil grease or other flammable contaminants shall not be used with oxygen equipment (item 8-6222) and Flammable and combustible liquids shall not be permitted within the site of intentional expulsion (item 8-6223) There is no evidence of any danger
Petroleum Jelly and Oxygen
1) Winslow EH Jacobson AF Dispelling the petroleum jelly myth AM J
Nurs199898(11)16)
2) Phippen ML Is petroleum jelly safe AM J Nurs 1999 99(8)24
3) Woodrow P Petroleum jelly myth Nurs Older People 2004 16(6) 41
Are there any adverse incidents reported in the literature There are NO case reports of adverse incidents with Vaseline applied to lips
1) Ocak I1 Raffensperger J Turkbey B Fuhrman C Lipid pneumonia secondary to
Petroleum jelly use in a patient with tympanic membrane perforation JBR-BTR
2009 Nov-Dec92(6)280-2
2) Gorospe L1 Gallego-Rivera JI Hervaacutes-Moroacuten A Exogenous lipoid pneumonia
secondary to Petroleum jelly application to the tracheostomy in a laryngectomy
patient PETCT and MR imaging findings Clin Imaging 2013 Jan-Feb37(1)163-
6 doi 101016jclinimag201202002 Epub 2012 Jun 8
Is there a fire risk
There have been some reports of surgical ignitions of
various materials such as Chlorhexidine and
Tracheostomy plastic These took place in a surgical
setting with high concentrations of oxygen and with a
clear ignition source most commonly diathermy
cauterization
NOT Vaseline
1) Gorphe P1 Sarfati B2 Janot F2 Bourgain JL3 Motamed C3 Blot F3
Temam S2 Airway fire during tracheostomy Eur Ann Otorhinolaryngol
Head Neck Dis 2014 Jun131(3)197-9 doi
101016janorl201307001 Epub 2014 Apr 1
2) Bengezi O2 Third-degree burns caused by ignition of chlorhexidine A
case report and systematic review of the literature Plast Surg (Oakv)
2014 Winter22(4)264-6 Vo A1
The Material Safety Data Sheets by Sasol demonstrate the flash
point of petroleum jelly to be around 150 degrees Celsius and an
autoignition temperature of around 320 degrees Celsius
This is way above normal environmental encounters and consistent
with plastics considered very safe
(For example Polyvinyl chloride (PVC) Flash point 250 degrees and
Ignition temp 450 degrees)
1) Sasol Material Safety Data Sheet ndash Petroleum Jelly Revision date
1142011 Created by BShamase approved by Ephraim Papo
Vaseline is flammable right
httpswwwyoutubecomwatchv=8hAUKTnHlcg
Petroleum jelly without oxygen - blow torch
httpswwwyoutubecomwatchv=yLqixjvTD7s
Petroleum jelly mixed with oxygen - blow torch
httpswwwyoutubecomwatchv=asumR-n2e6k
Oxygen Tubing
Ignition with lighter Ignition with blow torch
Petroleum jelly on
it own
Melted never ignited Melted 120 seconds to
ignite
Petroleum jelly
mixed with oxygen
10min (high flow)
Melted never ignited Melted 111 second to
ignite
Cotton wool on its
own
Ignition 3 seconds burn
time 45 seconds
Ignition instant burn time
40 seconds
Cotton wool mixed
with petroleum jelly
Ignition 11 seconds
burn time 197 seconds
Ignition instant burn time
113 seconds
Oxygen tubing Ignition 18 seconds
burn time 10 seconds
Ignition instant burn time
8 seconds
In gathering the opinions of 52 carers and nursing colleagues in
Bedford Hospital Addenbrooks and Sue Ryder Hospice in relation
to the use of petroleum Jelly with oxygen the following concerns
were highlighted
1) Risk of blame if anything untoward happens
2) Potential to be told off by seniors
3) Must not challenge policy even if I personally disagree
4) The change would not be sustained by my colleagues
A lot of resistancehellip Why
There is no evidence that Vaseline is superior to aqueous products at maintaining moisture in the mouth Howeverhellip In my expereince (and I would argue the vast majority of carers and nurses) would use vaseline for themselves and think its superior to aquos products What do you think
28
Brushing teeth
1 Hale KJ American Academy of Pediatrics Section on Pediatric
Dentistry Oral health risk assessment timing and establishment
of the dental home Pediatrics 2003 1111113
2 Beltraacuten-Aguilar ED Barker LK Canto MT et al Surveillance for
dental caries dental sealants tooth retention edentulism and
enamel fluorosis--United States 1988-1994 and 1999-2002
MMWR Surveill Summ 2005 541
3 NIDR the prevalence of dental caries in United States children
The National Caries Prevalence Survey 1979-1989 NIH
Publication 82-2245 National Instutute of Dental Research
National Caries Program 1981
4 Brunelle JA Oral health of United States children The National
Survey of Dental Caries in US School Children 1986-1987 NIH
Publication 9-2247 National Institute of Dental Research
Epidemiology and Disease Prevention Program 1989
5 Kelly JE Harvey CR Basic data on dental examination findings
of persons 1-74 years United States 1971-1974 Vital Health
Stat 11 1979 1
There is clear consensus throughout dental literature regarding the importance of regular brushing with a fluoride toothpaste - generally recommending after every meal
Are we brushing teeth NI Hospice I was assured we were brushing teeth at least twice day So I measured ithellip A single night 7 out of the 13 patients got their teeth brushed twicendash NI hospice St Johns Hospice Sue Ryder That would never happen to us we definitely do it twice day So I measured ithellip 13 out of 20 patients got their teeth brushed twice - St Johns Hospice Severn Hospice Community Of also interesting note do not rinse your mouth afterwards to allow fluoride to act
Non foaming toothpaste
Sodium laureth sulfate (SLS) or sodium lauryl ether sulfate (SLES) is a detergent and surfactant found in many personal care products (soaps shampoos toothpastes etc) bull It makes the toothpaste froth
bull SLS Free toothpastes are available
bull Make sure they are fluoride based
bull Less drying than normal toothpaste
bull Take a while to get used to
31
Denture Care
bull A huge area and confusing
bull A lot of different products and makes
bull Dependent upon what the denture is made of ie type of plastic and if contains metal or ceramic or not
bull All do come with their own recommendations
bull Recommend taking dentures out and soaking overnight withhellip
bull Chlorhexadine 02 MW is safe with all (however risks staining the teeth pink) bull Steradent is also very safe as a cleaning agent
bull Toothpaste (with or without fluoride) is corroding and dentures should not be
brushed with this rather use soap and water and rinse well
bull If remaining teeth they should be brushed as normal with fluoride toothpaste
bull Dentures should be taken out at night unless strong patient preference to leave in
32
Painful mouth
I collated a local guideline on the evidence available from the sources mentioned earlier and then expert opinion from my colleagues as to the order and preferences
bull Is it mucositis (Recent chemo or radiotherapy)
bull Recommendations of a baby (soft) toothbrushes to examine a mouth and clean a mucky mouth
bull Some evidence for Benzydamine Hydrochloride 015 oral rinse (Difflam) 10-15ml rinsegargle for 20-30sec QDS Benzydamine Hydrochloride Oromucosal spray 015 QDS
bull Most common problem is battling onhellip If treatment stings stop and re-assess
bull Many other options
Thrush
It is very difficult on occasion to differentiate between a coated mouth and thrush A couple of possible useful differentiating factors (although none are certain) - open for discussion 1) plaques on softhard palate (anywhere but tongue) - more likely thrush 2) Isolated on tongue - less likely thrush 3) plaques easily cleaned away with soft toothbrush - less likely thrush 4) mucky plaques - less likely thrush With all considerations made and there could be duel pathology consider a trail of treatment in conjunction with good oral hygiene care
35
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had had an input
Re audited the ward on the 17th June
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
bull There are to date no randomised controlled trials demonstrating a superiority of any
individual mouth care products or oral saliva replacement products to each other in a
palliative population
bull Systematic literature review Xerostomia in advanced cancer patients (Supportive Care
in Cancer vol 23(3) Oct 2014)
bull The aim of this review was to determine the effectiveness of pharmacological and non-
pharmacological interventions in treating xerostomia in adult advanced cancer patients
Literature Search
bull Results
ndash 3 RCTs and 3 prospective studies
ndash Compared acupuncture pilocarpine Saliva Orthana and chewing gum with placebo
ndash All interventions were considered effective in treating xerostomia to equal effect
ndash However effectiveness versus placebo often could not be demonstrated statistically significantly
ndash No meta analysis possible ndash too small
bull Conclusion
ndash Limited published data exists so no firm conclusions can be drawn
ndash However pilocarpine artificial saliva chewing gum and acupuncture have some evidence
ndash This highlights the explicit need to improve our evidence base Properly constructed RCTs are
required
bull Systematic literature review Xerostomia in advanced cancer patients (Supportive Care in
Cancer vol 23(3) Oct 2014)
bull Palliative Medicine as a whole recommend a variety of oral saliva replacement products and
mouth washes for the management of xerostomia often based on familiarity and ad-hoc
experience rather than guidelines or evidence
bull Last year I organised with Dr Conn Haughey for all of MDT to try a large selection of
mouthcare products and contrasted our current clinical practice before trying the products
and after (approx 60 different health care professionals tried the products)
Before and After Top 5 amp Top 3 Top 5 rankings
before Top 5 rankings
after Top 3 rankings
before Top 3 rankings
after
Oral balance (Biotene) gel (47)
Biotene moisturising
mouthwash (36)
Oral balance (Biotene) gel (33)
Biotene moisturising
mouthwash (29)
Biotene moisturising
mouthwash (35)
Sugar free chewing gum (35)
Biotene moisturising
mouthwash (30)
Sugar free chewing gum (21)
Glandosane (natural) spray (34)
Salivix sugar free pastilles (30)
Glandosane (natural) spray (16)
Oral balance (Biotene) gelSips of water (1616)
Sugar free chewing gum (24)
Oral balance (Biotene) gelSips of water (2525)
Sips of water (13) Salivix sugar free pastilles (13)
Sips of water (21) Sugar free chewing gum (9)
0
3
5
8
10
13
COB MG RM KS DF GS EH SM EM MG MP AM FH
overall dryness score
overall dryness score
patient
overall dryness score
COB 0
MG 4
RM 4
KS 5
DF 5
GS 5
EH 6
SM 6
EM 8
MG 8
MP 9
AM 9
FH 10
Mean 62
0 ndash not dry - normal 10 ndash as dry as can be
29515 and 2615
Removed 4 patients 2 could not respond 1 inappropriate 1 confused
13
Mouthcare Pre
Patient Biotene Nystatin Salivex other
COB 0 0 0 0
MG 0 0 0 0
RM 0 1 0 0
KS 1 0 0 chewing gum
DF 1 0 1 0
GS 0 0 0 0
EH 1 0 1 Daktarin
SM 1 1 1 0
EM 1 1 0 0
MG 0 0 0 0
MP 0 0 0 0
AM 1 1 1 0
FH 1 0 1 occasional
lollies
7 4 5
Most had no product
It became clear a local guideline needed to be constructed to consolidate this new information and create consistency across our practice in Northern Ireland Bedford Cambridge Shrewsbury I searched and collated other sources of information and guidelines on Xereostomia includinghellip 1) PCF5 (p599) 2) Dental and Oral Care chart (RVH) 3) Dental and Oral Hygiene Chart (Dental School) 4) Marie Curie Oral Assessment tool 5) Oxford handbook on Palliative Care 6) PANG guidelines (p64) 7) uptodate website 8) European Essential Palliative Care certificate 9) Belfast Dental School 10)Bedford Mouthcare protocol
11) Addenbrooks - Good oral care 12) BMJ ndash oral care
16
Failed flow diagram
It also became evident there was huge overlap between xerostomia and other aspects of mouth care in particular including management of Thrush management of painful mouth and Denture care These aspects where all inseparable Issues raised and noted 1) Difficulty diagnosis of thrush ( coating) 2) Denture care (using toothbrushes masking thrushulcers) 3) Vaseline - not with oxygen 4) Brushing teeth once day 5) Unclear guidelines on painful mouth
The guideline clearly also had to incorporate and clarify these aspects
This myth is based on the National Fire Protection Associations (NFPA) 1996 edition of its Standard for Health Care Facilities which states Oil grease or other flammable contaminants shall not be used with oxygen equipment (item 8-6222) and Flammable and combustible liquids shall not be permitted within the site of intentional expulsion (item 8-6223) There is no evidence of any danger
Petroleum Jelly and Oxygen
1) Winslow EH Jacobson AF Dispelling the petroleum jelly myth AM J
Nurs199898(11)16)
2) Phippen ML Is petroleum jelly safe AM J Nurs 1999 99(8)24
3) Woodrow P Petroleum jelly myth Nurs Older People 2004 16(6) 41
Are there any adverse incidents reported in the literature There are NO case reports of adverse incidents with Vaseline applied to lips
1) Ocak I1 Raffensperger J Turkbey B Fuhrman C Lipid pneumonia secondary to
Petroleum jelly use in a patient with tympanic membrane perforation JBR-BTR
2009 Nov-Dec92(6)280-2
2) Gorospe L1 Gallego-Rivera JI Hervaacutes-Moroacuten A Exogenous lipoid pneumonia
secondary to Petroleum jelly application to the tracheostomy in a laryngectomy
patient PETCT and MR imaging findings Clin Imaging 2013 Jan-Feb37(1)163-
6 doi 101016jclinimag201202002 Epub 2012 Jun 8
Is there a fire risk
There have been some reports of surgical ignitions of
various materials such as Chlorhexidine and
Tracheostomy plastic These took place in a surgical
setting with high concentrations of oxygen and with a
clear ignition source most commonly diathermy
cauterization
NOT Vaseline
1) Gorphe P1 Sarfati B2 Janot F2 Bourgain JL3 Motamed C3 Blot F3
Temam S2 Airway fire during tracheostomy Eur Ann Otorhinolaryngol
Head Neck Dis 2014 Jun131(3)197-9 doi
101016janorl201307001 Epub 2014 Apr 1
2) Bengezi O2 Third-degree burns caused by ignition of chlorhexidine A
case report and systematic review of the literature Plast Surg (Oakv)
2014 Winter22(4)264-6 Vo A1
The Material Safety Data Sheets by Sasol demonstrate the flash
point of petroleum jelly to be around 150 degrees Celsius and an
autoignition temperature of around 320 degrees Celsius
This is way above normal environmental encounters and consistent
with plastics considered very safe
(For example Polyvinyl chloride (PVC) Flash point 250 degrees and
Ignition temp 450 degrees)
1) Sasol Material Safety Data Sheet ndash Petroleum Jelly Revision date
1142011 Created by BShamase approved by Ephraim Papo
Vaseline is flammable right
httpswwwyoutubecomwatchv=8hAUKTnHlcg
Petroleum jelly without oxygen - blow torch
httpswwwyoutubecomwatchv=yLqixjvTD7s
Petroleum jelly mixed with oxygen - blow torch
httpswwwyoutubecomwatchv=asumR-n2e6k
Oxygen Tubing
Ignition with lighter Ignition with blow torch
Petroleum jelly on
it own
Melted never ignited Melted 120 seconds to
ignite
Petroleum jelly
mixed with oxygen
10min (high flow)
Melted never ignited Melted 111 second to
ignite
Cotton wool on its
own
Ignition 3 seconds burn
time 45 seconds
Ignition instant burn time
40 seconds
Cotton wool mixed
with petroleum jelly
Ignition 11 seconds
burn time 197 seconds
Ignition instant burn time
113 seconds
Oxygen tubing Ignition 18 seconds
burn time 10 seconds
Ignition instant burn time
8 seconds
In gathering the opinions of 52 carers and nursing colleagues in
Bedford Hospital Addenbrooks and Sue Ryder Hospice in relation
to the use of petroleum Jelly with oxygen the following concerns
were highlighted
1) Risk of blame if anything untoward happens
2) Potential to be told off by seniors
3) Must not challenge policy even if I personally disagree
4) The change would not be sustained by my colleagues
A lot of resistancehellip Why
There is no evidence that Vaseline is superior to aqueous products at maintaining moisture in the mouth Howeverhellip In my expereince (and I would argue the vast majority of carers and nurses) would use vaseline for themselves and think its superior to aquos products What do you think
28
Brushing teeth
1 Hale KJ American Academy of Pediatrics Section on Pediatric
Dentistry Oral health risk assessment timing and establishment
of the dental home Pediatrics 2003 1111113
2 Beltraacuten-Aguilar ED Barker LK Canto MT et al Surveillance for
dental caries dental sealants tooth retention edentulism and
enamel fluorosis--United States 1988-1994 and 1999-2002
MMWR Surveill Summ 2005 541
3 NIDR the prevalence of dental caries in United States children
The National Caries Prevalence Survey 1979-1989 NIH
Publication 82-2245 National Instutute of Dental Research
National Caries Program 1981
4 Brunelle JA Oral health of United States children The National
Survey of Dental Caries in US School Children 1986-1987 NIH
Publication 9-2247 National Institute of Dental Research
Epidemiology and Disease Prevention Program 1989
5 Kelly JE Harvey CR Basic data on dental examination findings
of persons 1-74 years United States 1971-1974 Vital Health
Stat 11 1979 1
There is clear consensus throughout dental literature regarding the importance of regular brushing with a fluoride toothpaste - generally recommending after every meal
Are we brushing teeth NI Hospice I was assured we were brushing teeth at least twice day So I measured ithellip A single night 7 out of the 13 patients got their teeth brushed twicendash NI hospice St Johns Hospice Sue Ryder That would never happen to us we definitely do it twice day So I measured ithellip 13 out of 20 patients got their teeth brushed twice - St Johns Hospice Severn Hospice Community Of also interesting note do not rinse your mouth afterwards to allow fluoride to act
Non foaming toothpaste
Sodium laureth sulfate (SLS) or sodium lauryl ether sulfate (SLES) is a detergent and surfactant found in many personal care products (soaps shampoos toothpastes etc) bull It makes the toothpaste froth
bull SLS Free toothpastes are available
bull Make sure they are fluoride based
bull Less drying than normal toothpaste
bull Take a while to get used to
31
Denture Care
bull A huge area and confusing
bull A lot of different products and makes
bull Dependent upon what the denture is made of ie type of plastic and if contains metal or ceramic or not
bull All do come with their own recommendations
bull Recommend taking dentures out and soaking overnight withhellip
bull Chlorhexadine 02 MW is safe with all (however risks staining the teeth pink) bull Steradent is also very safe as a cleaning agent
bull Toothpaste (with or without fluoride) is corroding and dentures should not be
brushed with this rather use soap and water and rinse well
bull If remaining teeth they should be brushed as normal with fluoride toothpaste
bull Dentures should be taken out at night unless strong patient preference to leave in
32
Painful mouth
I collated a local guideline on the evidence available from the sources mentioned earlier and then expert opinion from my colleagues as to the order and preferences
bull Is it mucositis (Recent chemo or radiotherapy)
bull Recommendations of a baby (soft) toothbrushes to examine a mouth and clean a mucky mouth
bull Some evidence for Benzydamine Hydrochloride 015 oral rinse (Difflam) 10-15ml rinsegargle for 20-30sec QDS Benzydamine Hydrochloride Oromucosal spray 015 QDS
bull Most common problem is battling onhellip If treatment stings stop and re-assess
bull Many other options
Thrush
It is very difficult on occasion to differentiate between a coated mouth and thrush A couple of possible useful differentiating factors (although none are certain) - open for discussion 1) plaques on softhard palate (anywhere but tongue) - more likely thrush 2) Isolated on tongue - less likely thrush 3) plaques easily cleaned away with soft toothbrush - less likely thrush 4) mucky plaques - less likely thrush With all considerations made and there could be duel pathology consider a trail of treatment in conjunction with good oral hygiene care
35
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had had an input
Re audited the ward on the 17th June
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
bull Results
ndash 3 RCTs and 3 prospective studies
ndash Compared acupuncture pilocarpine Saliva Orthana and chewing gum with placebo
ndash All interventions were considered effective in treating xerostomia to equal effect
ndash However effectiveness versus placebo often could not be demonstrated statistically significantly
ndash No meta analysis possible ndash too small
bull Conclusion
ndash Limited published data exists so no firm conclusions can be drawn
ndash However pilocarpine artificial saliva chewing gum and acupuncture have some evidence
ndash This highlights the explicit need to improve our evidence base Properly constructed RCTs are
required
bull Systematic literature review Xerostomia in advanced cancer patients (Supportive Care in
Cancer vol 23(3) Oct 2014)
bull Palliative Medicine as a whole recommend a variety of oral saliva replacement products and
mouth washes for the management of xerostomia often based on familiarity and ad-hoc
experience rather than guidelines or evidence
bull Last year I organised with Dr Conn Haughey for all of MDT to try a large selection of
mouthcare products and contrasted our current clinical practice before trying the products
and after (approx 60 different health care professionals tried the products)
Before and After Top 5 amp Top 3 Top 5 rankings
before Top 5 rankings
after Top 3 rankings
before Top 3 rankings
after
Oral balance (Biotene) gel (47)
Biotene moisturising
mouthwash (36)
Oral balance (Biotene) gel (33)
Biotene moisturising
mouthwash (29)
Biotene moisturising
mouthwash (35)
Sugar free chewing gum (35)
Biotene moisturising
mouthwash (30)
Sugar free chewing gum (21)
Glandosane (natural) spray (34)
Salivix sugar free pastilles (30)
Glandosane (natural) spray (16)
Oral balance (Biotene) gelSips of water (1616)
Sugar free chewing gum (24)
Oral balance (Biotene) gelSips of water (2525)
Sips of water (13) Salivix sugar free pastilles (13)
Sips of water (21) Sugar free chewing gum (9)
0
3
5
8
10
13
COB MG RM KS DF GS EH SM EM MG MP AM FH
overall dryness score
overall dryness score
patient
overall dryness score
COB 0
MG 4
RM 4
KS 5
DF 5
GS 5
EH 6
SM 6
EM 8
MG 8
MP 9
AM 9
FH 10
Mean 62
0 ndash not dry - normal 10 ndash as dry as can be
29515 and 2615
Removed 4 patients 2 could not respond 1 inappropriate 1 confused
13
Mouthcare Pre
Patient Biotene Nystatin Salivex other
COB 0 0 0 0
MG 0 0 0 0
RM 0 1 0 0
KS 1 0 0 chewing gum
DF 1 0 1 0
GS 0 0 0 0
EH 1 0 1 Daktarin
SM 1 1 1 0
EM 1 1 0 0
MG 0 0 0 0
MP 0 0 0 0
AM 1 1 1 0
FH 1 0 1 occasional
lollies
7 4 5
Most had no product
It became clear a local guideline needed to be constructed to consolidate this new information and create consistency across our practice in Northern Ireland Bedford Cambridge Shrewsbury I searched and collated other sources of information and guidelines on Xereostomia includinghellip 1) PCF5 (p599) 2) Dental and Oral Care chart (RVH) 3) Dental and Oral Hygiene Chart (Dental School) 4) Marie Curie Oral Assessment tool 5) Oxford handbook on Palliative Care 6) PANG guidelines (p64) 7) uptodate website 8) European Essential Palliative Care certificate 9) Belfast Dental School 10)Bedford Mouthcare protocol
11) Addenbrooks - Good oral care 12) BMJ ndash oral care
16
Failed flow diagram
It also became evident there was huge overlap between xerostomia and other aspects of mouth care in particular including management of Thrush management of painful mouth and Denture care These aspects where all inseparable Issues raised and noted 1) Difficulty diagnosis of thrush ( coating) 2) Denture care (using toothbrushes masking thrushulcers) 3) Vaseline - not with oxygen 4) Brushing teeth once day 5) Unclear guidelines on painful mouth
The guideline clearly also had to incorporate and clarify these aspects
This myth is based on the National Fire Protection Associations (NFPA) 1996 edition of its Standard for Health Care Facilities which states Oil grease or other flammable contaminants shall not be used with oxygen equipment (item 8-6222) and Flammable and combustible liquids shall not be permitted within the site of intentional expulsion (item 8-6223) There is no evidence of any danger
Petroleum Jelly and Oxygen
1) Winslow EH Jacobson AF Dispelling the petroleum jelly myth AM J
Nurs199898(11)16)
2) Phippen ML Is petroleum jelly safe AM J Nurs 1999 99(8)24
3) Woodrow P Petroleum jelly myth Nurs Older People 2004 16(6) 41
Are there any adverse incidents reported in the literature There are NO case reports of adverse incidents with Vaseline applied to lips
1) Ocak I1 Raffensperger J Turkbey B Fuhrman C Lipid pneumonia secondary to
Petroleum jelly use in a patient with tympanic membrane perforation JBR-BTR
2009 Nov-Dec92(6)280-2
2) Gorospe L1 Gallego-Rivera JI Hervaacutes-Moroacuten A Exogenous lipoid pneumonia
secondary to Petroleum jelly application to the tracheostomy in a laryngectomy
patient PETCT and MR imaging findings Clin Imaging 2013 Jan-Feb37(1)163-
6 doi 101016jclinimag201202002 Epub 2012 Jun 8
Is there a fire risk
There have been some reports of surgical ignitions of
various materials such as Chlorhexidine and
Tracheostomy plastic These took place in a surgical
setting with high concentrations of oxygen and with a
clear ignition source most commonly diathermy
cauterization
NOT Vaseline
1) Gorphe P1 Sarfati B2 Janot F2 Bourgain JL3 Motamed C3 Blot F3
Temam S2 Airway fire during tracheostomy Eur Ann Otorhinolaryngol
Head Neck Dis 2014 Jun131(3)197-9 doi
101016janorl201307001 Epub 2014 Apr 1
2) Bengezi O2 Third-degree burns caused by ignition of chlorhexidine A
case report and systematic review of the literature Plast Surg (Oakv)
2014 Winter22(4)264-6 Vo A1
The Material Safety Data Sheets by Sasol demonstrate the flash
point of petroleum jelly to be around 150 degrees Celsius and an
autoignition temperature of around 320 degrees Celsius
This is way above normal environmental encounters and consistent
with plastics considered very safe
(For example Polyvinyl chloride (PVC) Flash point 250 degrees and
Ignition temp 450 degrees)
1) Sasol Material Safety Data Sheet ndash Petroleum Jelly Revision date
1142011 Created by BShamase approved by Ephraim Papo
Vaseline is flammable right
httpswwwyoutubecomwatchv=8hAUKTnHlcg
Petroleum jelly without oxygen - blow torch
httpswwwyoutubecomwatchv=yLqixjvTD7s
Petroleum jelly mixed with oxygen - blow torch
httpswwwyoutubecomwatchv=asumR-n2e6k
Oxygen Tubing
Ignition with lighter Ignition with blow torch
Petroleum jelly on
it own
Melted never ignited Melted 120 seconds to
ignite
Petroleum jelly
mixed with oxygen
10min (high flow)
Melted never ignited Melted 111 second to
ignite
Cotton wool on its
own
Ignition 3 seconds burn
time 45 seconds
Ignition instant burn time
40 seconds
Cotton wool mixed
with petroleum jelly
Ignition 11 seconds
burn time 197 seconds
Ignition instant burn time
113 seconds
Oxygen tubing Ignition 18 seconds
burn time 10 seconds
Ignition instant burn time
8 seconds
In gathering the opinions of 52 carers and nursing colleagues in
Bedford Hospital Addenbrooks and Sue Ryder Hospice in relation
to the use of petroleum Jelly with oxygen the following concerns
were highlighted
1) Risk of blame if anything untoward happens
2) Potential to be told off by seniors
3) Must not challenge policy even if I personally disagree
4) The change would not be sustained by my colleagues
A lot of resistancehellip Why
There is no evidence that Vaseline is superior to aqueous products at maintaining moisture in the mouth Howeverhellip In my expereince (and I would argue the vast majority of carers and nurses) would use vaseline for themselves and think its superior to aquos products What do you think
28
Brushing teeth
1 Hale KJ American Academy of Pediatrics Section on Pediatric
Dentistry Oral health risk assessment timing and establishment
of the dental home Pediatrics 2003 1111113
2 Beltraacuten-Aguilar ED Barker LK Canto MT et al Surveillance for
dental caries dental sealants tooth retention edentulism and
enamel fluorosis--United States 1988-1994 and 1999-2002
MMWR Surveill Summ 2005 541
3 NIDR the prevalence of dental caries in United States children
The National Caries Prevalence Survey 1979-1989 NIH
Publication 82-2245 National Instutute of Dental Research
National Caries Program 1981
4 Brunelle JA Oral health of United States children The National
Survey of Dental Caries in US School Children 1986-1987 NIH
Publication 9-2247 National Institute of Dental Research
Epidemiology and Disease Prevention Program 1989
5 Kelly JE Harvey CR Basic data on dental examination findings
of persons 1-74 years United States 1971-1974 Vital Health
Stat 11 1979 1
There is clear consensus throughout dental literature regarding the importance of regular brushing with a fluoride toothpaste - generally recommending after every meal
Are we brushing teeth NI Hospice I was assured we were brushing teeth at least twice day So I measured ithellip A single night 7 out of the 13 patients got their teeth brushed twicendash NI hospice St Johns Hospice Sue Ryder That would never happen to us we definitely do it twice day So I measured ithellip 13 out of 20 patients got their teeth brushed twice - St Johns Hospice Severn Hospice Community Of also interesting note do not rinse your mouth afterwards to allow fluoride to act
Non foaming toothpaste
Sodium laureth sulfate (SLS) or sodium lauryl ether sulfate (SLES) is a detergent and surfactant found in many personal care products (soaps shampoos toothpastes etc) bull It makes the toothpaste froth
bull SLS Free toothpastes are available
bull Make sure they are fluoride based
bull Less drying than normal toothpaste
bull Take a while to get used to
31
Denture Care
bull A huge area and confusing
bull A lot of different products and makes
bull Dependent upon what the denture is made of ie type of plastic and if contains metal or ceramic or not
bull All do come with their own recommendations
bull Recommend taking dentures out and soaking overnight withhellip
bull Chlorhexadine 02 MW is safe with all (however risks staining the teeth pink) bull Steradent is also very safe as a cleaning agent
bull Toothpaste (with or without fluoride) is corroding and dentures should not be
brushed with this rather use soap and water and rinse well
bull If remaining teeth they should be brushed as normal with fluoride toothpaste
bull Dentures should be taken out at night unless strong patient preference to leave in
32
Painful mouth
I collated a local guideline on the evidence available from the sources mentioned earlier and then expert opinion from my colleagues as to the order and preferences
bull Is it mucositis (Recent chemo or radiotherapy)
bull Recommendations of a baby (soft) toothbrushes to examine a mouth and clean a mucky mouth
bull Some evidence for Benzydamine Hydrochloride 015 oral rinse (Difflam) 10-15ml rinsegargle for 20-30sec QDS Benzydamine Hydrochloride Oromucosal spray 015 QDS
bull Most common problem is battling onhellip If treatment stings stop and re-assess
bull Many other options
Thrush
It is very difficult on occasion to differentiate between a coated mouth and thrush A couple of possible useful differentiating factors (although none are certain) - open for discussion 1) plaques on softhard palate (anywhere but tongue) - more likely thrush 2) Isolated on tongue - less likely thrush 3) plaques easily cleaned away with soft toothbrush - less likely thrush 4) mucky plaques - less likely thrush With all considerations made and there could be duel pathology consider a trail of treatment in conjunction with good oral hygiene care
35
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had had an input
Re audited the ward on the 17th June
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
bull Palliative Medicine as a whole recommend a variety of oral saliva replacement products and
mouth washes for the management of xerostomia often based on familiarity and ad-hoc
experience rather than guidelines or evidence
bull Last year I organised with Dr Conn Haughey for all of MDT to try a large selection of
mouthcare products and contrasted our current clinical practice before trying the products
and after (approx 60 different health care professionals tried the products)
Before and After Top 5 amp Top 3 Top 5 rankings
before Top 5 rankings
after Top 3 rankings
before Top 3 rankings
after
Oral balance (Biotene) gel (47)
Biotene moisturising
mouthwash (36)
Oral balance (Biotene) gel (33)
Biotene moisturising
mouthwash (29)
Biotene moisturising
mouthwash (35)
Sugar free chewing gum (35)
Biotene moisturising
mouthwash (30)
Sugar free chewing gum (21)
Glandosane (natural) spray (34)
Salivix sugar free pastilles (30)
Glandosane (natural) spray (16)
Oral balance (Biotene) gelSips of water (1616)
Sugar free chewing gum (24)
Oral balance (Biotene) gelSips of water (2525)
Sips of water (13) Salivix sugar free pastilles (13)
Sips of water (21) Sugar free chewing gum (9)
0
3
5
8
10
13
COB MG RM KS DF GS EH SM EM MG MP AM FH
overall dryness score
overall dryness score
patient
overall dryness score
COB 0
MG 4
RM 4
KS 5
DF 5
GS 5
EH 6
SM 6
EM 8
MG 8
MP 9
AM 9
FH 10
Mean 62
0 ndash not dry - normal 10 ndash as dry as can be
29515 and 2615
Removed 4 patients 2 could not respond 1 inappropriate 1 confused
13
Mouthcare Pre
Patient Biotene Nystatin Salivex other
COB 0 0 0 0
MG 0 0 0 0
RM 0 1 0 0
KS 1 0 0 chewing gum
DF 1 0 1 0
GS 0 0 0 0
EH 1 0 1 Daktarin
SM 1 1 1 0
EM 1 1 0 0
MG 0 0 0 0
MP 0 0 0 0
AM 1 1 1 0
FH 1 0 1 occasional
lollies
7 4 5
Most had no product
It became clear a local guideline needed to be constructed to consolidate this new information and create consistency across our practice in Northern Ireland Bedford Cambridge Shrewsbury I searched and collated other sources of information and guidelines on Xereostomia includinghellip 1) PCF5 (p599) 2) Dental and Oral Care chart (RVH) 3) Dental and Oral Hygiene Chart (Dental School) 4) Marie Curie Oral Assessment tool 5) Oxford handbook on Palliative Care 6) PANG guidelines (p64) 7) uptodate website 8) European Essential Palliative Care certificate 9) Belfast Dental School 10)Bedford Mouthcare protocol
11) Addenbrooks - Good oral care 12) BMJ ndash oral care
16
Failed flow diagram
It also became evident there was huge overlap between xerostomia and other aspects of mouth care in particular including management of Thrush management of painful mouth and Denture care These aspects where all inseparable Issues raised and noted 1) Difficulty diagnosis of thrush ( coating) 2) Denture care (using toothbrushes masking thrushulcers) 3) Vaseline - not with oxygen 4) Brushing teeth once day 5) Unclear guidelines on painful mouth
The guideline clearly also had to incorporate and clarify these aspects
This myth is based on the National Fire Protection Associations (NFPA) 1996 edition of its Standard for Health Care Facilities which states Oil grease or other flammable contaminants shall not be used with oxygen equipment (item 8-6222) and Flammable and combustible liquids shall not be permitted within the site of intentional expulsion (item 8-6223) There is no evidence of any danger
Petroleum Jelly and Oxygen
1) Winslow EH Jacobson AF Dispelling the petroleum jelly myth AM J
Nurs199898(11)16)
2) Phippen ML Is petroleum jelly safe AM J Nurs 1999 99(8)24
3) Woodrow P Petroleum jelly myth Nurs Older People 2004 16(6) 41
Are there any adverse incidents reported in the literature There are NO case reports of adverse incidents with Vaseline applied to lips
1) Ocak I1 Raffensperger J Turkbey B Fuhrman C Lipid pneumonia secondary to
Petroleum jelly use in a patient with tympanic membrane perforation JBR-BTR
2009 Nov-Dec92(6)280-2
2) Gorospe L1 Gallego-Rivera JI Hervaacutes-Moroacuten A Exogenous lipoid pneumonia
secondary to Petroleum jelly application to the tracheostomy in a laryngectomy
patient PETCT and MR imaging findings Clin Imaging 2013 Jan-Feb37(1)163-
6 doi 101016jclinimag201202002 Epub 2012 Jun 8
Is there a fire risk
There have been some reports of surgical ignitions of
various materials such as Chlorhexidine and
Tracheostomy plastic These took place in a surgical
setting with high concentrations of oxygen and with a
clear ignition source most commonly diathermy
cauterization
NOT Vaseline
1) Gorphe P1 Sarfati B2 Janot F2 Bourgain JL3 Motamed C3 Blot F3
Temam S2 Airway fire during tracheostomy Eur Ann Otorhinolaryngol
Head Neck Dis 2014 Jun131(3)197-9 doi
101016janorl201307001 Epub 2014 Apr 1
2) Bengezi O2 Third-degree burns caused by ignition of chlorhexidine A
case report and systematic review of the literature Plast Surg (Oakv)
2014 Winter22(4)264-6 Vo A1
The Material Safety Data Sheets by Sasol demonstrate the flash
point of petroleum jelly to be around 150 degrees Celsius and an
autoignition temperature of around 320 degrees Celsius
This is way above normal environmental encounters and consistent
with plastics considered very safe
(For example Polyvinyl chloride (PVC) Flash point 250 degrees and
Ignition temp 450 degrees)
1) Sasol Material Safety Data Sheet ndash Petroleum Jelly Revision date
1142011 Created by BShamase approved by Ephraim Papo
Vaseline is flammable right
httpswwwyoutubecomwatchv=8hAUKTnHlcg
Petroleum jelly without oxygen - blow torch
httpswwwyoutubecomwatchv=yLqixjvTD7s
Petroleum jelly mixed with oxygen - blow torch
httpswwwyoutubecomwatchv=asumR-n2e6k
Oxygen Tubing
Ignition with lighter Ignition with blow torch
Petroleum jelly on
it own
Melted never ignited Melted 120 seconds to
ignite
Petroleum jelly
mixed with oxygen
10min (high flow)
Melted never ignited Melted 111 second to
ignite
Cotton wool on its
own
Ignition 3 seconds burn
time 45 seconds
Ignition instant burn time
40 seconds
Cotton wool mixed
with petroleum jelly
Ignition 11 seconds
burn time 197 seconds
Ignition instant burn time
113 seconds
Oxygen tubing Ignition 18 seconds
burn time 10 seconds
Ignition instant burn time
8 seconds
In gathering the opinions of 52 carers and nursing colleagues in
Bedford Hospital Addenbrooks and Sue Ryder Hospice in relation
to the use of petroleum Jelly with oxygen the following concerns
were highlighted
1) Risk of blame if anything untoward happens
2) Potential to be told off by seniors
3) Must not challenge policy even if I personally disagree
4) The change would not be sustained by my colleagues
A lot of resistancehellip Why
There is no evidence that Vaseline is superior to aqueous products at maintaining moisture in the mouth Howeverhellip In my expereince (and I would argue the vast majority of carers and nurses) would use vaseline for themselves and think its superior to aquos products What do you think
28
Brushing teeth
1 Hale KJ American Academy of Pediatrics Section on Pediatric
Dentistry Oral health risk assessment timing and establishment
of the dental home Pediatrics 2003 1111113
2 Beltraacuten-Aguilar ED Barker LK Canto MT et al Surveillance for
dental caries dental sealants tooth retention edentulism and
enamel fluorosis--United States 1988-1994 and 1999-2002
MMWR Surveill Summ 2005 541
3 NIDR the prevalence of dental caries in United States children
The National Caries Prevalence Survey 1979-1989 NIH
Publication 82-2245 National Instutute of Dental Research
National Caries Program 1981
4 Brunelle JA Oral health of United States children The National
Survey of Dental Caries in US School Children 1986-1987 NIH
Publication 9-2247 National Institute of Dental Research
Epidemiology and Disease Prevention Program 1989
5 Kelly JE Harvey CR Basic data on dental examination findings
of persons 1-74 years United States 1971-1974 Vital Health
Stat 11 1979 1
There is clear consensus throughout dental literature regarding the importance of regular brushing with a fluoride toothpaste - generally recommending after every meal
Are we brushing teeth NI Hospice I was assured we were brushing teeth at least twice day So I measured ithellip A single night 7 out of the 13 patients got their teeth brushed twicendash NI hospice St Johns Hospice Sue Ryder That would never happen to us we definitely do it twice day So I measured ithellip 13 out of 20 patients got their teeth brushed twice - St Johns Hospice Severn Hospice Community Of also interesting note do not rinse your mouth afterwards to allow fluoride to act
Non foaming toothpaste
Sodium laureth sulfate (SLS) or sodium lauryl ether sulfate (SLES) is a detergent and surfactant found in many personal care products (soaps shampoos toothpastes etc) bull It makes the toothpaste froth
bull SLS Free toothpastes are available
bull Make sure they are fluoride based
bull Less drying than normal toothpaste
bull Take a while to get used to
31
Denture Care
bull A huge area and confusing
bull A lot of different products and makes
bull Dependent upon what the denture is made of ie type of plastic and if contains metal or ceramic or not
bull All do come with their own recommendations
bull Recommend taking dentures out and soaking overnight withhellip
bull Chlorhexadine 02 MW is safe with all (however risks staining the teeth pink) bull Steradent is also very safe as a cleaning agent
bull Toothpaste (with or without fluoride) is corroding and dentures should not be
brushed with this rather use soap and water and rinse well
bull If remaining teeth they should be brushed as normal with fluoride toothpaste
bull Dentures should be taken out at night unless strong patient preference to leave in
32
Painful mouth
I collated a local guideline on the evidence available from the sources mentioned earlier and then expert opinion from my colleagues as to the order and preferences
bull Is it mucositis (Recent chemo or radiotherapy)
bull Recommendations of a baby (soft) toothbrushes to examine a mouth and clean a mucky mouth
bull Some evidence for Benzydamine Hydrochloride 015 oral rinse (Difflam) 10-15ml rinsegargle for 20-30sec QDS Benzydamine Hydrochloride Oromucosal spray 015 QDS
bull Most common problem is battling onhellip If treatment stings stop and re-assess
bull Many other options
Thrush
It is very difficult on occasion to differentiate between a coated mouth and thrush A couple of possible useful differentiating factors (although none are certain) - open for discussion 1) plaques on softhard palate (anywhere but tongue) - more likely thrush 2) Isolated on tongue - less likely thrush 3) plaques easily cleaned away with soft toothbrush - less likely thrush 4) mucky plaques - less likely thrush With all considerations made and there could be duel pathology consider a trail of treatment in conjunction with good oral hygiene care
35
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had had an input
Re audited the ward on the 17th June
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
Before and After Top 5 amp Top 3 Top 5 rankings
before Top 5 rankings
after Top 3 rankings
before Top 3 rankings
after
Oral balance (Biotene) gel (47)
Biotene moisturising
mouthwash (36)
Oral balance (Biotene) gel (33)
Biotene moisturising
mouthwash (29)
Biotene moisturising
mouthwash (35)
Sugar free chewing gum (35)
Biotene moisturising
mouthwash (30)
Sugar free chewing gum (21)
Glandosane (natural) spray (34)
Salivix sugar free pastilles (30)
Glandosane (natural) spray (16)
Oral balance (Biotene) gelSips of water (1616)
Sugar free chewing gum (24)
Oral balance (Biotene) gelSips of water (2525)
Sips of water (13) Salivix sugar free pastilles (13)
Sips of water (21) Sugar free chewing gum (9)
0
3
5
8
10
13
COB MG RM KS DF GS EH SM EM MG MP AM FH
overall dryness score
overall dryness score
patient
overall dryness score
COB 0
MG 4
RM 4
KS 5
DF 5
GS 5
EH 6
SM 6
EM 8
MG 8
MP 9
AM 9
FH 10
Mean 62
0 ndash not dry - normal 10 ndash as dry as can be
29515 and 2615
Removed 4 patients 2 could not respond 1 inappropriate 1 confused
13
Mouthcare Pre
Patient Biotene Nystatin Salivex other
COB 0 0 0 0
MG 0 0 0 0
RM 0 1 0 0
KS 1 0 0 chewing gum
DF 1 0 1 0
GS 0 0 0 0
EH 1 0 1 Daktarin
SM 1 1 1 0
EM 1 1 0 0
MG 0 0 0 0
MP 0 0 0 0
AM 1 1 1 0
FH 1 0 1 occasional
lollies
7 4 5
Most had no product
It became clear a local guideline needed to be constructed to consolidate this new information and create consistency across our practice in Northern Ireland Bedford Cambridge Shrewsbury I searched and collated other sources of information and guidelines on Xereostomia includinghellip 1) PCF5 (p599) 2) Dental and Oral Care chart (RVH) 3) Dental and Oral Hygiene Chart (Dental School) 4) Marie Curie Oral Assessment tool 5) Oxford handbook on Palliative Care 6) PANG guidelines (p64) 7) uptodate website 8) European Essential Palliative Care certificate 9) Belfast Dental School 10)Bedford Mouthcare protocol
11) Addenbrooks - Good oral care 12) BMJ ndash oral care
16
Failed flow diagram
It also became evident there was huge overlap between xerostomia and other aspects of mouth care in particular including management of Thrush management of painful mouth and Denture care These aspects where all inseparable Issues raised and noted 1) Difficulty diagnosis of thrush ( coating) 2) Denture care (using toothbrushes masking thrushulcers) 3) Vaseline - not with oxygen 4) Brushing teeth once day 5) Unclear guidelines on painful mouth
The guideline clearly also had to incorporate and clarify these aspects
This myth is based on the National Fire Protection Associations (NFPA) 1996 edition of its Standard for Health Care Facilities which states Oil grease or other flammable contaminants shall not be used with oxygen equipment (item 8-6222) and Flammable and combustible liquids shall not be permitted within the site of intentional expulsion (item 8-6223) There is no evidence of any danger
Petroleum Jelly and Oxygen
1) Winslow EH Jacobson AF Dispelling the petroleum jelly myth AM J
Nurs199898(11)16)
2) Phippen ML Is petroleum jelly safe AM J Nurs 1999 99(8)24
3) Woodrow P Petroleum jelly myth Nurs Older People 2004 16(6) 41
Are there any adverse incidents reported in the literature There are NO case reports of adverse incidents with Vaseline applied to lips
1) Ocak I1 Raffensperger J Turkbey B Fuhrman C Lipid pneumonia secondary to
Petroleum jelly use in a patient with tympanic membrane perforation JBR-BTR
2009 Nov-Dec92(6)280-2
2) Gorospe L1 Gallego-Rivera JI Hervaacutes-Moroacuten A Exogenous lipoid pneumonia
secondary to Petroleum jelly application to the tracheostomy in a laryngectomy
patient PETCT and MR imaging findings Clin Imaging 2013 Jan-Feb37(1)163-
6 doi 101016jclinimag201202002 Epub 2012 Jun 8
Is there a fire risk
There have been some reports of surgical ignitions of
various materials such as Chlorhexidine and
Tracheostomy plastic These took place in a surgical
setting with high concentrations of oxygen and with a
clear ignition source most commonly diathermy
cauterization
NOT Vaseline
1) Gorphe P1 Sarfati B2 Janot F2 Bourgain JL3 Motamed C3 Blot F3
Temam S2 Airway fire during tracheostomy Eur Ann Otorhinolaryngol
Head Neck Dis 2014 Jun131(3)197-9 doi
101016janorl201307001 Epub 2014 Apr 1
2) Bengezi O2 Third-degree burns caused by ignition of chlorhexidine A
case report and systematic review of the literature Plast Surg (Oakv)
2014 Winter22(4)264-6 Vo A1
The Material Safety Data Sheets by Sasol demonstrate the flash
point of petroleum jelly to be around 150 degrees Celsius and an
autoignition temperature of around 320 degrees Celsius
This is way above normal environmental encounters and consistent
with plastics considered very safe
(For example Polyvinyl chloride (PVC) Flash point 250 degrees and
Ignition temp 450 degrees)
1) Sasol Material Safety Data Sheet ndash Petroleum Jelly Revision date
1142011 Created by BShamase approved by Ephraim Papo
Vaseline is flammable right
httpswwwyoutubecomwatchv=8hAUKTnHlcg
Petroleum jelly without oxygen - blow torch
httpswwwyoutubecomwatchv=yLqixjvTD7s
Petroleum jelly mixed with oxygen - blow torch
httpswwwyoutubecomwatchv=asumR-n2e6k
Oxygen Tubing
Ignition with lighter Ignition with blow torch
Petroleum jelly on
it own
Melted never ignited Melted 120 seconds to
ignite
Petroleum jelly
mixed with oxygen
10min (high flow)
Melted never ignited Melted 111 second to
ignite
Cotton wool on its
own
Ignition 3 seconds burn
time 45 seconds
Ignition instant burn time
40 seconds
Cotton wool mixed
with petroleum jelly
Ignition 11 seconds
burn time 197 seconds
Ignition instant burn time
113 seconds
Oxygen tubing Ignition 18 seconds
burn time 10 seconds
Ignition instant burn time
8 seconds
In gathering the opinions of 52 carers and nursing colleagues in
Bedford Hospital Addenbrooks and Sue Ryder Hospice in relation
to the use of petroleum Jelly with oxygen the following concerns
were highlighted
1) Risk of blame if anything untoward happens
2) Potential to be told off by seniors
3) Must not challenge policy even if I personally disagree
4) The change would not be sustained by my colleagues
A lot of resistancehellip Why
There is no evidence that Vaseline is superior to aqueous products at maintaining moisture in the mouth Howeverhellip In my expereince (and I would argue the vast majority of carers and nurses) would use vaseline for themselves and think its superior to aquos products What do you think
28
Brushing teeth
1 Hale KJ American Academy of Pediatrics Section on Pediatric
Dentistry Oral health risk assessment timing and establishment
of the dental home Pediatrics 2003 1111113
2 Beltraacuten-Aguilar ED Barker LK Canto MT et al Surveillance for
dental caries dental sealants tooth retention edentulism and
enamel fluorosis--United States 1988-1994 and 1999-2002
MMWR Surveill Summ 2005 541
3 NIDR the prevalence of dental caries in United States children
The National Caries Prevalence Survey 1979-1989 NIH
Publication 82-2245 National Instutute of Dental Research
National Caries Program 1981
4 Brunelle JA Oral health of United States children The National
Survey of Dental Caries in US School Children 1986-1987 NIH
Publication 9-2247 National Institute of Dental Research
Epidemiology and Disease Prevention Program 1989
5 Kelly JE Harvey CR Basic data on dental examination findings
of persons 1-74 years United States 1971-1974 Vital Health
Stat 11 1979 1
There is clear consensus throughout dental literature regarding the importance of regular brushing with a fluoride toothpaste - generally recommending after every meal
Are we brushing teeth NI Hospice I was assured we were brushing teeth at least twice day So I measured ithellip A single night 7 out of the 13 patients got their teeth brushed twicendash NI hospice St Johns Hospice Sue Ryder That would never happen to us we definitely do it twice day So I measured ithellip 13 out of 20 patients got their teeth brushed twice - St Johns Hospice Severn Hospice Community Of also interesting note do not rinse your mouth afterwards to allow fluoride to act
Non foaming toothpaste
Sodium laureth sulfate (SLS) or sodium lauryl ether sulfate (SLES) is a detergent and surfactant found in many personal care products (soaps shampoos toothpastes etc) bull It makes the toothpaste froth
bull SLS Free toothpastes are available
bull Make sure they are fluoride based
bull Less drying than normal toothpaste
bull Take a while to get used to
31
Denture Care
bull A huge area and confusing
bull A lot of different products and makes
bull Dependent upon what the denture is made of ie type of plastic and if contains metal or ceramic or not
bull All do come with their own recommendations
bull Recommend taking dentures out and soaking overnight withhellip
bull Chlorhexadine 02 MW is safe with all (however risks staining the teeth pink) bull Steradent is also very safe as a cleaning agent
bull Toothpaste (with or without fluoride) is corroding and dentures should not be
brushed with this rather use soap and water and rinse well
bull If remaining teeth they should be brushed as normal with fluoride toothpaste
bull Dentures should be taken out at night unless strong patient preference to leave in
32
Painful mouth
I collated a local guideline on the evidence available from the sources mentioned earlier and then expert opinion from my colleagues as to the order and preferences
bull Is it mucositis (Recent chemo or radiotherapy)
bull Recommendations of a baby (soft) toothbrushes to examine a mouth and clean a mucky mouth
bull Some evidence for Benzydamine Hydrochloride 015 oral rinse (Difflam) 10-15ml rinsegargle for 20-30sec QDS Benzydamine Hydrochloride Oromucosal spray 015 QDS
bull Most common problem is battling onhellip If treatment stings stop and re-assess
bull Many other options
Thrush
It is very difficult on occasion to differentiate between a coated mouth and thrush A couple of possible useful differentiating factors (although none are certain) - open for discussion 1) plaques on softhard palate (anywhere but tongue) - more likely thrush 2) Isolated on tongue - less likely thrush 3) plaques easily cleaned away with soft toothbrush - less likely thrush 4) mucky plaques - less likely thrush With all considerations made and there could be duel pathology consider a trail of treatment in conjunction with good oral hygiene care
35
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had had an input
Re audited the ward on the 17th June
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
0
3
5
8
10
13
COB MG RM KS DF GS EH SM EM MG MP AM FH
overall dryness score
overall dryness score
patient
overall dryness score
COB 0
MG 4
RM 4
KS 5
DF 5
GS 5
EH 6
SM 6
EM 8
MG 8
MP 9
AM 9
FH 10
Mean 62
0 ndash not dry - normal 10 ndash as dry as can be
29515 and 2615
Removed 4 patients 2 could not respond 1 inappropriate 1 confused
13
Mouthcare Pre
Patient Biotene Nystatin Salivex other
COB 0 0 0 0
MG 0 0 0 0
RM 0 1 0 0
KS 1 0 0 chewing gum
DF 1 0 1 0
GS 0 0 0 0
EH 1 0 1 Daktarin
SM 1 1 1 0
EM 1 1 0 0
MG 0 0 0 0
MP 0 0 0 0
AM 1 1 1 0
FH 1 0 1 occasional
lollies
7 4 5
Most had no product
It became clear a local guideline needed to be constructed to consolidate this new information and create consistency across our practice in Northern Ireland Bedford Cambridge Shrewsbury I searched and collated other sources of information and guidelines on Xereostomia includinghellip 1) PCF5 (p599) 2) Dental and Oral Care chart (RVH) 3) Dental and Oral Hygiene Chart (Dental School) 4) Marie Curie Oral Assessment tool 5) Oxford handbook on Palliative Care 6) PANG guidelines (p64) 7) uptodate website 8) European Essential Palliative Care certificate 9) Belfast Dental School 10)Bedford Mouthcare protocol
11) Addenbrooks - Good oral care 12) BMJ ndash oral care
16
Failed flow diagram
It also became evident there was huge overlap between xerostomia and other aspects of mouth care in particular including management of Thrush management of painful mouth and Denture care These aspects where all inseparable Issues raised and noted 1) Difficulty diagnosis of thrush ( coating) 2) Denture care (using toothbrushes masking thrushulcers) 3) Vaseline - not with oxygen 4) Brushing teeth once day 5) Unclear guidelines on painful mouth
The guideline clearly also had to incorporate and clarify these aspects
This myth is based on the National Fire Protection Associations (NFPA) 1996 edition of its Standard for Health Care Facilities which states Oil grease or other flammable contaminants shall not be used with oxygen equipment (item 8-6222) and Flammable and combustible liquids shall not be permitted within the site of intentional expulsion (item 8-6223) There is no evidence of any danger
Petroleum Jelly and Oxygen
1) Winslow EH Jacobson AF Dispelling the petroleum jelly myth AM J
Nurs199898(11)16)
2) Phippen ML Is petroleum jelly safe AM J Nurs 1999 99(8)24
3) Woodrow P Petroleum jelly myth Nurs Older People 2004 16(6) 41
Are there any adverse incidents reported in the literature There are NO case reports of adverse incidents with Vaseline applied to lips
1) Ocak I1 Raffensperger J Turkbey B Fuhrman C Lipid pneumonia secondary to
Petroleum jelly use in a patient with tympanic membrane perforation JBR-BTR
2009 Nov-Dec92(6)280-2
2) Gorospe L1 Gallego-Rivera JI Hervaacutes-Moroacuten A Exogenous lipoid pneumonia
secondary to Petroleum jelly application to the tracheostomy in a laryngectomy
patient PETCT and MR imaging findings Clin Imaging 2013 Jan-Feb37(1)163-
6 doi 101016jclinimag201202002 Epub 2012 Jun 8
Is there a fire risk
There have been some reports of surgical ignitions of
various materials such as Chlorhexidine and
Tracheostomy plastic These took place in a surgical
setting with high concentrations of oxygen and with a
clear ignition source most commonly diathermy
cauterization
NOT Vaseline
1) Gorphe P1 Sarfati B2 Janot F2 Bourgain JL3 Motamed C3 Blot F3
Temam S2 Airway fire during tracheostomy Eur Ann Otorhinolaryngol
Head Neck Dis 2014 Jun131(3)197-9 doi
101016janorl201307001 Epub 2014 Apr 1
2) Bengezi O2 Third-degree burns caused by ignition of chlorhexidine A
case report and systematic review of the literature Plast Surg (Oakv)
2014 Winter22(4)264-6 Vo A1
The Material Safety Data Sheets by Sasol demonstrate the flash
point of petroleum jelly to be around 150 degrees Celsius and an
autoignition temperature of around 320 degrees Celsius
This is way above normal environmental encounters and consistent
with plastics considered very safe
(For example Polyvinyl chloride (PVC) Flash point 250 degrees and
Ignition temp 450 degrees)
1) Sasol Material Safety Data Sheet ndash Petroleum Jelly Revision date
1142011 Created by BShamase approved by Ephraim Papo
Vaseline is flammable right
httpswwwyoutubecomwatchv=8hAUKTnHlcg
Petroleum jelly without oxygen - blow torch
httpswwwyoutubecomwatchv=yLqixjvTD7s
Petroleum jelly mixed with oxygen - blow torch
httpswwwyoutubecomwatchv=asumR-n2e6k
Oxygen Tubing
Ignition with lighter Ignition with blow torch
Petroleum jelly on
it own
Melted never ignited Melted 120 seconds to
ignite
Petroleum jelly
mixed with oxygen
10min (high flow)
Melted never ignited Melted 111 second to
ignite
Cotton wool on its
own
Ignition 3 seconds burn
time 45 seconds
Ignition instant burn time
40 seconds
Cotton wool mixed
with petroleum jelly
Ignition 11 seconds
burn time 197 seconds
Ignition instant burn time
113 seconds
Oxygen tubing Ignition 18 seconds
burn time 10 seconds
Ignition instant burn time
8 seconds
In gathering the opinions of 52 carers and nursing colleagues in
Bedford Hospital Addenbrooks and Sue Ryder Hospice in relation
to the use of petroleum Jelly with oxygen the following concerns
were highlighted
1) Risk of blame if anything untoward happens
2) Potential to be told off by seniors
3) Must not challenge policy even if I personally disagree
4) The change would not be sustained by my colleagues
A lot of resistancehellip Why
There is no evidence that Vaseline is superior to aqueous products at maintaining moisture in the mouth Howeverhellip In my expereince (and I would argue the vast majority of carers and nurses) would use vaseline for themselves and think its superior to aquos products What do you think
28
Brushing teeth
1 Hale KJ American Academy of Pediatrics Section on Pediatric
Dentistry Oral health risk assessment timing and establishment
of the dental home Pediatrics 2003 1111113
2 Beltraacuten-Aguilar ED Barker LK Canto MT et al Surveillance for
dental caries dental sealants tooth retention edentulism and
enamel fluorosis--United States 1988-1994 and 1999-2002
MMWR Surveill Summ 2005 541
3 NIDR the prevalence of dental caries in United States children
The National Caries Prevalence Survey 1979-1989 NIH
Publication 82-2245 National Instutute of Dental Research
National Caries Program 1981
4 Brunelle JA Oral health of United States children The National
Survey of Dental Caries in US School Children 1986-1987 NIH
Publication 9-2247 National Institute of Dental Research
Epidemiology and Disease Prevention Program 1989
5 Kelly JE Harvey CR Basic data on dental examination findings
of persons 1-74 years United States 1971-1974 Vital Health
Stat 11 1979 1
There is clear consensus throughout dental literature regarding the importance of regular brushing with a fluoride toothpaste - generally recommending after every meal
Are we brushing teeth NI Hospice I was assured we were brushing teeth at least twice day So I measured ithellip A single night 7 out of the 13 patients got their teeth brushed twicendash NI hospice St Johns Hospice Sue Ryder That would never happen to us we definitely do it twice day So I measured ithellip 13 out of 20 patients got their teeth brushed twice - St Johns Hospice Severn Hospice Community Of also interesting note do not rinse your mouth afterwards to allow fluoride to act
Non foaming toothpaste
Sodium laureth sulfate (SLS) or sodium lauryl ether sulfate (SLES) is a detergent and surfactant found in many personal care products (soaps shampoos toothpastes etc) bull It makes the toothpaste froth
bull SLS Free toothpastes are available
bull Make sure they are fluoride based
bull Less drying than normal toothpaste
bull Take a while to get used to
31
Denture Care
bull A huge area and confusing
bull A lot of different products and makes
bull Dependent upon what the denture is made of ie type of plastic and if contains metal or ceramic or not
bull All do come with their own recommendations
bull Recommend taking dentures out and soaking overnight withhellip
bull Chlorhexadine 02 MW is safe with all (however risks staining the teeth pink) bull Steradent is also very safe as a cleaning agent
bull Toothpaste (with or without fluoride) is corroding and dentures should not be
brushed with this rather use soap and water and rinse well
bull If remaining teeth they should be brushed as normal with fluoride toothpaste
bull Dentures should be taken out at night unless strong patient preference to leave in
32
Painful mouth
I collated a local guideline on the evidence available from the sources mentioned earlier and then expert opinion from my colleagues as to the order and preferences
bull Is it mucositis (Recent chemo or radiotherapy)
bull Recommendations of a baby (soft) toothbrushes to examine a mouth and clean a mucky mouth
bull Some evidence for Benzydamine Hydrochloride 015 oral rinse (Difflam) 10-15ml rinsegargle for 20-30sec QDS Benzydamine Hydrochloride Oromucosal spray 015 QDS
bull Most common problem is battling onhellip If treatment stings stop and re-assess
bull Many other options
Thrush
It is very difficult on occasion to differentiate between a coated mouth and thrush A couple of possible useful differentiating factors (although none are certain) - open for discussion 1) plaques on softhard palate (anywhere but tongue) - more likely thrush 2) Isolated on tongue - less likely thrush 3) plaques easily cleaned away with soft toothbrush - less likely thrush 4) mucky plaques - less likely thrush With all considerations made and there could be duel pathology consider a trail of treatment in conjunction with good oral hygiene care
35
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had had an input
Re audited the ward on the 17th June
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
13
Mouthcare Pre
Patient Biotene Nystatin Salivex other
COB 0 0 0 0
MG 0 0 0 0
RM 0 1 0 0
KS 1 0 0 chewing gum
DF 1 0 1 0
GS 0 0 0 0
EH 1 0 1 Daktarin
SM 1 1 1 0
EM 1 1 0 0
MG 0 0 0 0
MP 0 0 0 0
AM 1 1 1 0
FH 1 0 1 occasional
lollies
7 4 5
Most had no product
It became clear a local guideline needed to be constructed to consolidate this new information and create consistency across our practice in Northern Ireland Bedford Cambridge Shrewsbury I searched and collated other sources of information and guidelines on Xereostomia includinghellip 1) PCF5 (p599) 2) Dental and Oral Care chart (RVH) 3) Dental and Oral Hygiene Chart (Dental School) 4) Marie Curie Oral Assessment tool 5) Oxford handbook on Palliative Care 6) PANG guidelines (p64) 7) uptodate website 8) European Essential Palliative Care certificate 9) Belfast Dental School 10)Bedford Mouthcare protocol
11) Addenbrooks - Good oral care 12) BMJ ndash oral care
16
Failed flow diagram
It also became evident there was huge overlap between xerostomia and other aspects of mouth care in particular including management of Thrush management of painful mouth and Denture care These aspects where all inseparable Issues raised and noted 1) Difficulty diagnosis of thrush ( coating) 2) Denture care (using toothbrushes masking thrushulcers) 3) Vaseline - not with oxygen 4) Brushing teeth once day 5) Unclear guidelines on painful mouth
The guideline clearly also had to incorporate and clarify these aspects
This myth is based on the National Fire Protection Associations (NFPA) 1996 edition of its Standard for Health Care Facilities which states Oil grease or other flammable contaminants shall not be used with oxygen equipment (item 8-6222) and Flammable and combustible liquids shall not be permitted within the site of intentional expulsion (item 8-6223) There is no evidence of any danger
Petroleum Jelly and Oxygen
1) Winslow EH Jacobson AF Dispelling the petroleum jelly myth AM J
Nurs199898(11)16)
2) Phippen ML Is petroleum jelly safe AM J Nurs 1999 99(8)24
3) Woodrow P Petroleum jelly myth Nurs Older People 2004 16(6) 41
Are there any adverse incidents reported in the literature There are NO case reports of adverse incidents with Vaseline applied to lips
1) Ocak I1 Raffensperger J Turkbey B Fuhrman C Lipid pneumonia secondary to
Petroleum jelly use in a patient with tympanic membrane perforation JBR-BTR
2009 Nov-Dec92(6)280-2
2) Gorospe L1 Gallego-Rivera JI Hervaacutes-Moroacuten A Exogenous lipoid pneumonia
secondary to Petroleum jelly application to the tracheostomy in a laryngectomy
patient PETCT and MR imaging findings Clin Imaging 2013 Jan-Feb37(1)163-
6 doi 101016jclinimag201202002 Epub 2012 Jun 8
Is there a fire risk
There have been some reports of surgical ignitions of
various materials such as Chlorhexidine and
Tracheostomy plastic These took place in a surgical
setting with high concentrations of oxygen and with a
clear ignition source most commonly diathermy
cauterization
NOT Vaseline
1) Gorphe P1 Sarfati B2 Janot F2 Bourgain JL3 Motamed C3 Blot F3
Temam S2 Airway fire during tracheostomy Eur Ann Otorhinolaryngol
Head Neck Dis 2014 Jun131(3)197-9 doi
101016janorl201307001 Epub 2014 Apr 1
2) Bengezi O2 Third-degree burns caused by ignition of chlorhexidine A
case report and systematic review of the literature Plast Surg (Oakv)
2014 Winter22(4)264-6 Vo A1
The Material Safety Data Sheets by Sasol demonstrate the flash
point of petroleum jelly to be around 150 degrees Celsius and an
autoignition temperature of around 320 degrees Celsius
This is way above normal environmental encounters and consistent
with plastics considered very safe
(For example Polyvinyl chloride (PVC) Flash point 250 degrees and
Ignition temp 450 degrees)
1) Sasol Material Safety Data Sheet ndash Petroleum Jelly Revision date
1142011 Created by BShamase approved by Ephraim Papo
Vaseline is flammable right
httpswwwyoutubecomwatchv=8hAUKTnHlcg
Petroleum jelly without oxygen - blow torch
httpswwwyoutubecomwatchv=yLqixjvTD7s
Petroleum jelly mixed with oxygen - blow torch
httpswwwyoutubecomwatchv=asumR-n2e6k
Oxygen Tubing
Ignition with lighter Ignition with blow torch
Petroleum jelly on
it own
Melted never ignited Melted 120 seconds to
ignite
Petroleum jelly
mixed with oxygen
10min (high flow)
Melted never ignited Melted 111 second to
ignite
Cotton wool on its
own
Ignition 3 seconds burn
time 45 seconds
Ignition instant burn time
40 seconds
Cotton wool mixed
with petroleum jelly
Ignition 11 seconds
burn time 197 seconds
Ignition instant burn time
113 seconds
Oxygen tubing Ignition 18 seconds
burn time 10 seconds
Ignition instant burn time
8 seconds
In gathering the opinions of 52 carers and nursing colleagues in
Bedford Hospital Addenbrooks and Sue Ryder Hospice in relation
to the use of petroleum Jelly with oxygen the following concerns
were highlighted
1) Risk of blame if anything untoward happens
2) Potential to be told off by seniors
3) Must not challenge policy even if I personally disagree
4) The change would not be sustained by my colleagues
A lot of resistancehellip Why
There is no evidence that Vaseline is superior to aqueous products at maintaining moisture in the mouth Howeverhellip In my expereince (and I would argue the vast majority of carers and nurses) would use vaseline for themselves and think its superior to aquos products What do you think
28
Brushing teeth
1 Hale KJ American Academy of Pediatrics Section on Pediatric
Dentistry Oral health risk assessment timing and establishment
of the dental home Pediatrics 2003 1111113
2 Beltraacuten-Aguilar ED Barker LK Canto MT et al Surveillance for
dental caries dental sealants tooth retention edentulism and
enamel fluorosis--United States 1988-1994 and 1999-2002
MMWR Surveill Summ 2005 541
3 NIDR the prevalence of dental caries in United States children
The National Caries Prevalence Survey 1979-1989 NIH
Publication 82-2245 National Instutute of Dental Research
National Caries Program 1981
4 Brunelle JA Oral health of United States children The National
Survey of Dental Caries in US School Children 1986-1987 NIH
Publication 9-2247 National Institute of Dental Research
Epidemiology and Disease Prevention Program 1989
5 Kelly JE Harvey CR Basic data on dental examination findings
of persons 1-74 years United States 1971-1974 Vital Health
Stat 11 1979 1
There is clear consensus throughout dental literature regarding the importance of regular brushing with a fluoride toothpaste - generally recommending after every meal
Are we brushing teeth NI Hospice I was assured we were brushing teeth at least twice day So I measured ithellip A single night 7 out of the 13 patients got their teeth brushed twicendash NI hospice St Johns Hospice Sue Ryder That would never happen to us we definitely do it twice day So I measured ithellip 13 out of 20 patients got their teeth brushed twice - St Johns Hospice Severn Hospice Community Of also interesting note do not rinse your mouth afterwards to allow fluoride to act
Non foaming toothpaste
Sodium laureth sulfate (SLS) or sodium lauryl ether sulfate (SLES) is a detergent and surfactant found in many personal care products (soaps shampoos toothpastes etc) bull It makes the toothpaste froth
bull SLS Free toothpastes are available
bull Make sure they are fluoride based
bull Less drying than normal toothpaste
bull Take a while to get used to
31
Denture Care
bull A huge area and confusing
bull A lot of different products and makes
bull Dependent upon what the denture is made of ie type of plastic and if contains metal or ceramic or not
bull All do come with their own recommendations
bull Recommend taking dentures out and soaking overnight withhellip
bull Chlorhexadine 02 MW is safe with all (however risks staining the teeth pink) bull Steradent is also very safe as a cleaning agent
bull Toothpaste (with or without fluoride) is corroding and dentures should not be
brushed with this rather use soap and water and rinse well
bull If remaining teeth they should be brushed as normal with fluoride toothpaste
bull Dentures should be taken out at night unless strong patient preference to leave in
32
Painful mouth
I collated a local guideline on the evidence available from the sources mentioned earlier and then expert opinion from my colleagues as to the order and preferences
bull Is it mucositis (Recent chemo or radiotherapy)
bull Recommendations of a baby (soft) toothbrushes to examine a mouth and clean a mucky mouth
bull Some evidence for Benzydamine Hydrochloride 015 oral rinse (Difflam) 10-15ml rinsegargle for 20-30sec QDS Benzydamine Hydrochloride Oromucosal spray 015 QDS
bull Most common problem is battling onhellip If treatment stings stop and re-assess
bull Many other options
Thrush
It is very difficult on occasion to differentiate between a coated mouth and thrush A couple of possible useful differentiating factors (although none are certain) - open for discussion 1) plaques on softhard palate (anywhere but tongue) - more likely thrush 2) Isolated on tongue - less likely thrush 3) plaques easily cleaned away with soft toothbrush - less likely thrush 4) mucky plaques - less likely thrush With all considerations made and there could be duel pathology consider a trail of treatment in conjunction with good oral hygiene care
35
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had had an input
Re audited the ward on the 17th June
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
It became clear a local guideline needed to be constructed to consolidate this new information and create consistency across our practice in Northern Ireland Bedford Cambridge Shrewsbury I searched and collated other sources of information and guidelines on Xereostomia includinghellip 1) PCF5 (p599) 2) Dental and Oral Care chart (RVH) 3) Dental and Oral Hygiene Chart (Dental School) 4) Marie Curie Oral Assessment tool 5) Oxford handbook on Palliative Care 6) PANG guidelines (p64) 7) uptodate website 8) European Essential Palliative Care certificate 9) Belfast Dental School 10)Bedford Mouthcare protocol
11) Addenbrooks - Good oral care 12) BMJ ndash oral care
16
Failed flow diagram
It also became evident there was huge overlap between xerostomia and other aspects of mouth care in particular including management of Thrush management of painful mouth and Denture care These aspects where all inseparable Issues raised and noted 1) Difficulty diagnosis of thrush ( coating) 2) Denture care (using toothbrushes masking thrushulcers) 3) Vaseline - not with oxygen 4) Brushing teeth once day 5) Unclear guidelines on painful mouth
The guideline clearly also had to incorporate and clarify these aspects
This myth is based on the National Fire Protection Associations (NFPA) 1996 edition of its Standard for Health Care Facilities which states Oil grease or other flammable contaminants shall not be used with oxygen equipment (item 8-6222) and Flammable and combustible liquids shall not be permitted within the site of intentional expulsion (item 8-6223) There is no evidence of any danger
Petroleum Jelly and Oxygen
1) Winslow EH Jacobson AF Dispelling the petroleum jelly myth AM J
Nurs199898(11)16)
2) Phippen ML Is petroleum jelly safe AM J Nurs 1999 99(8)24
3) Woodrow P Petroleum jelly myth Nurs Older People 2004 16(6) 41
Are there any adverse incidents reported in the literature There are NO case reports of adverse incidents with Vaseline applied to lips
1) Ocak I1 Raffensperger J Turkbey B Fuhrman C Lipid pneumonia secondary to
Petroleum jelly use in a patient with tympanic membrane perforation JBR-BTR
2009 Nov-Dec92(6)280-2
2) Gorospe L1 Gallego-Rivera JI Hervaacutes-Moroacuten A Exogenous lipoid pneumonia
secondary to Petroleum jelly application to the tracheostomy in a laryngectomy
patient PETCT and MR imaging findings Clin Imaging 2013 Jan-Feb37(1)163-
6 doi 101016jclinimag201202002 Epub 2012 Jun 8
Is there a fire risk
There have been some reports of surgical ignitions of
various materials such as Chlorhexidine and
Tracheostomy plastic These took place in a surgical
setting with high concentrations of oxygen and with a
clear ignition source most commonly diathermy
cauterization
NOT Vaseline
1) Gorphe P1 Sarfati B2 Janot F2 Bourgain JL3 Motamed C3 Blot F3
Temam S2 Airway fire during tracheostomy Eur Ann Otorhinolaryngol
Head Neck Dis 2014 Jun131(3)197-9 doi
101016janorl201307001 Epub 2014 Apr 1
2) Bengezi O2 Third-degree burns caused by ignition of chlorhexidine A
case report and systematic review of the literature Plast Surg (Oakv)
2014 Winter22(4)264-6 Vo A1
The Material Safety Data Sheets by Sasol demonstrate the flash
point of petroleum jelly to be around 150 degrees Celsius and an
autoignition temperature of around 320 degrees Celsius
This is way above normal environmental encounters and consistent
with plastics considered very safe
(For example Polyvinyl chloride (PVC) Flash point 250 degrees and
Ignition temp 450 degrees)
1) Sasol Material Safety Data Sheet ndash Petroleum Jelly Revision date
1142011 Created by BShamase approved by Ephraim Papo
Vaseline is flammable right
httpswwwyoutubecomwatchv=8hAUKTnHlcg
Petroleum jelly without oxygen - blow torch
httpswwwyoutubecomwatchv=yLqixjvTD7s
Petroleum jelly mixed with oxygen - blow torch
httpswwwyoutubecomwatchv=asumR-n2e6k
Oxygen Tubing
Ignition with lighter Ignition with blow torch
Petroleum jelly on
it own
Melted never ignited Melted 120 seconds to
ignite
Petroleum jelly
mixed with oxygen
10min (high flow)
Melted never ignited Melted 111 second to
ignite
Cotton wool on its
own
Ignition 3 seconds burn
time 45 seconds
Ignition instant burn time
40 seconds
Cotton wool mixed
with petroleum jelly
Ignition 11 seconds
burn time 197 seconds
Ignition instant burn time
113 seconds
Oxygen tubing Ignition 18 seconds
burn time 10 seconds
Ignition instant burn time
8 seconds
In gathering the opinions of 52 carers and nursing colleagues in
Bedford Hospital Addenbrooks and Sue Ryder Hospice in relation
to the use of petroleum Jelly with oxygen the following concerns
were highlighted
1) Risk of blame if anything untoward happens
2) Potential to be told off by seniors
3) Must not challenge policy even if I personally disagree
4) The change would not be sustained by my colleagues
A lot of resistancehellip Why
There is no evidence that Vaseline is superior to aqueous products at maintaining moisture in the mouth Howeverhellip In my expereince (and I would argue the vast majority of carers and nurses) would use vaseline for themselves and think its superior to aquos products What do you think
28
Brushing teeth
1 Hale KJ American Academy of Pediatrics Section on Pediatric
Dentistry Oral health risk assessment timing and establishment
of the dental home Pediatrics 2003 1111113
2 Beltraacuten-Aguilar ED Barker LK Canto MT et al Surveillance for
dental caries dental sealants tooth retention edentulism and
enamel fluorosis--United States 1988-1994 and 1999-2002
MMWR Surveill Summ 2005 541
3 NIDR the prevalence of dental caries in United States children
The National Caries Prevalence Survey 1979-1989 NIH
Publication 82-2245 National Instutute of Dental Research
National Caries Program 1981
4 Brunelle JA Oral health of United States children The National
Survey of Dental Caries in US School Children 1986-1987 NIH
Publication 9-2247 National Institute of Dental Research
Epidemiology and Disease Prevention Program 1989
5 Kelly JE Harvey CR Basic data on dental examination findings
of persons 1-74 years United States 1971-1974 Vital Health
Stat 11 1979 1
There is clear consensus throughout dental literature regarding the importance of regular brushing with a fluoride toothpaste - generally recommending after every meal
Are we brushing teeth NI Hospice I was assured we were brushing teeth at least twice day So I measured ithellip A single night 7 out of the 13 patients got their teeth brushed twicendash NI hospice St Johns Hospice Sue Ryder That would never happen to us we definitely do it twice day So I measured ithellip 13 out of 20 patients got their teeth brushed twice - St Johns Hospice Severn Hospice Community Of also interesting note do not rinse your mouth afterwards to allow fluoride to act
Non foaming toothpaste
Sodium laureth sulfate (SLS) or sodium lauryl ether sulfate (SLES) is a detergent and surfactant found in many personal care products (soaps shampoos toothpastes etc) bull It makes the toothpaste froth
bull SLS Free toothpastes are available
bull Make sure they are fluoride based
bull Less drying than normal toothpaste
bull Take a while to get used to
31
Denture Care
bull A huge area and confusing
bull A lot of different products and makes
bull Dependent upon what the denture is made of ie type of plastic and if contains metal or ceramic or not
bull All do come with their own recommendations
bull Recommend taking dentures out and soaking overnight withhellip
bull Chlorhexadine 02 MW is safe with all (however risks staining the teeth pink) bull Steradent is also very safe as a cleaning agent
bull Toothpaste (with or without fluoride) is corroding and dentures should not be
brushed with this rather use soap and water and rinse well
bull If remaining teeth they should be brushed as normal with fluoride toothpaste
bull Dentures should be taken out at night unless strong patient preference to leave in
32
Painful mouth
I collated a local guideline on the evidence available from the sources mentioned earlier and then expert opinion from my colleagues as to the order and preferences
bull Is it mucositis (Recent chemo or radiotherapy)
bull Recommendations of a baby (soft) toothbrushes to examine a mouth and clean a mucky mouth
bull Some evidence for Benzydamine Hydrochloride 015 oral rinse (Difflam) 10-15ml rinsegargle for 20-30sec QDS Benzydamine Hydrochloride Oromucosal spray 015 QDS
bull Most common problem is battling onhellip If treatment stings stop and re-assess
bull Many other options
Thrush
It is very difficult on occasion to differentiate between a coated mouth and thrush A couple of possible useful differentiating factors (although none are certain) - open for discussion 1) plaques on softhard palate (anywhere but tongue) - more likely thrush 2) Isolated on tongue - less likely thrush 3) plaques easily cleaned away with soft toothbrush - less likely thrush 4) mucky plaques - less likely thrush With all considerations made and there could be duel pathology consider a trail of treatment in conjunction with good oral hygiene care
35
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had had an input
Re audited the ward on the 17th June
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
16
Failed flow diagram
It also became evident there was huge overlap between xerostomia and other aspects of mouth care in particular including management of Thrush management of painful mouth and Denture care These aspects where all inseparable Issues raised and noted 1) Difficulty diagnosis of thrush ( coating) 2) Denture care (using toothbrushes masking thrushulcers) 3) Vaseline - not with oxygen 4) Brushing teeth once day 5) Unclear guidelines on painful mouth
The guideline clearly also had to incorporate and clarify these aspects
This myth is based on the National Fire Protection Associations (NFPA) 1996 edition of its Standard for Health Care Facilities which states Oil grease or other flammable contaminants shall not be used with oxygen equipment (item 8-6222) and Flammable and combustible liquids shall not be permitted within the site of intentional expulsion (item 8-6223) There is no evidence of any danger
Petroleum Jelly and Oxygen
1) Winslow EH Jacobson AF Dispelling the petroleum jelly myth AM J
Nurs199898(11)16)
2) Phippen ML Is petroleum jelly safe AM J Nurs 1999 99(8)24
3) Woodrow P Petroleum jelly myth Nurs Older People 2004 16(6) 41
Are there any adverse incidents reported in the literature There are NO case reports of adverse incidents with Vaseline applied to lips
1) Ocak I1 Raffensperger J Turkbey B Fuhrman C Lipid pneumonia secondary to
Petroleum jelly use in a patient with tympanic membrane perforation JBR-BTR
2009 Nov-Dec92(6)280-2
2) Gorospe L1 Gallego-Rivera JI Hervaacutes-Moroacuten A Exogenous lipoid pneumonia
secondary to Petroleum jelly application to the tracheostomy in a laryngectomy
patient PETCT and MR imaging findings Clin Imaging 2013 Jan-Feb37(1)163-
6 doi 101016jclinimag201202002 Epub 2012 Jun 8
Is there a fire risk
There have been some reports of surgical ignitions of
various materials such as Chlorhexidine and
Tracheostomy plastic These took place in a surgical
setting with high concentrations of oxygen and with a
clear ignition source most commonly diathermy
cauterization
NOT Vaseline
1) Gorphe P1 Sarfati B2 Janot F2 Bourgain JL3 Motamed C3 Blot F3
Temam S2 Airway fire during tracheostomy Eur Ann Otorhinolaryngol
Head Neck Dis 2014 Jun131(3)197-9 doi
101016janorl201307001 Epub 2014 Apr 1
2) Bengezi O2 Third-degree burns caused by ignition of chlorhexidine A
case report and systematic review of the literature Plast Surg (Oakv)
2014 Winter22(4)264-6 Vo A1
The Material Safety Data Sheets by Sasol demonstrate the flash
point of petroleum jelly to be around 150 degrees Celsius and an
autoignition temperature of around 320 degrees Celsius
This is way above normal environmental encounters and consistent
with plastics considered very safe
(For example Polyvinyl chloride (PVC) Flash point 250 degrees and
Ignition temp 450 degrees)
1) Sasol Material Safety Data Sheet ndash Petroleum Jelly Revision date
1142011 Created by BShamase approved by Ephraim Papo
Vaseline is flammable right
httpswwwyoutubecomwatchv=8hAUKTnHlcg
Petroleum jelly without oxygen - blow torch
httpswwwyoutubecomwatchv=yLqixjvTD7s
Petroleum jelly mixed with oxygen - blow torch
httpswwwyoutubecomwatchv=asumR-n2e6k
Oxygen Tubing
Ignition with lighter Ignition with blow torch
Petroleum jelly on
it own
Melted never ignited Melted 120 seconds to
ignite
Petroleum jelly
mixed with oxygen
10min (high flow)
Melted never ignited Melted 111 second to
ignite
Cotton wool on its
own
Ignition 3 seconds burn
time 45 seconds
Ignition instant burn time
40 seconds
Cotton wool mixed
with petroleum jelly
Ignition 11 seconds
burn time 197 seconds
Ignition instant burn time
113 seconds
Oxygen tubing Ignition 18 seconds
burn time 10 seconds
Ignition instant burn time
8 seconds
In gathering the opinions of 52 carers and nursing colleagues in
Bedford Hospital Addenbrooks and Sue Ryder Hospice in relation
to the use of petroleum Jelly with oxygen the following concerns
were highlighted
1) Risk of blame if anything untoward happens
2) Potential to be told off by seniors
3) Must not challenge policy even if I personally disagree
4) The change would not be sustained by my colleagues
A lot of resistancehellip Why
There is no evidence that Vaseline is superior to aqueous products at maintaining moisture in the mouth Howeverhellip In my expereince (and I would argue the vast majority of carers and nurses) would use vaseline for themselves and think its superior to aquos products What do you think
28
Brushing teeth
1 Hale KJ American Academy of Pediatrics Section on Pediatric
Dentistry Oral health risk assessment timing and establishment
of the dental home Pediatrics 2003 1111113
2 Beltraacuten-Aguilar ED Barker LK Canto MT et al Surveillance for
dental caries dental sealants tooth retention edentulism and
enamel fluorosis--United States 1988-1994 and 1999-2002
MMWR Surveill Summ 2005 541
3 NIDR the prevalence of dental caries in United States children
The National Caries Prevalence Survey 1979-1989 NIH
Publication 82-2245 National Instutute of Dental Research
National Caries Program 1981
4 Brunelle JA Oral health of United States children The National
Survey of Dental Caries in US School Children 1986-1987 NIH
Publication 9-2247 National Institute of Dental Research
Epidemiology and Disease Prevention Program 1989
5 Kelly JE Harvey CR Basic data on dental examination findings
of persons 1-74 years United States 1971-1974 Vital Health
Stat 11 1979 1
There is clear consensus throughout dental literature regarding the importance of regular brushing with a fluoride toothpaste - generally recommending after every meal
Are we brushing teeth NI Hospice I was assured we were brushing teeth at least twice day So I measured ithellip A single night 7 out of the 13 patients got their teeth brushed twicendash NI hospice St Johns Hospice Sue Ryder That would never happen to us we definitely do it twice day So I measured ithellip 13 out of 20 patients got their teeth brushed twice - St Johns Hospice Severn Hospice Community Of also interesting note do not rinse your mouth afterwards to allow fluoride to act
Non foaming toothpaste
Sodium laureth sulfate (SLS) or sodium lauryl ether sulfate (SLES) is a detergent and surfactant found in many personal care products (soaps shampoos toothpastes etc) bull It makes the toothpaste froth
bull SLS Free toothpastes are available
bull Make sure they are fluoride based
bull Less drying than normal toothpaste
bull Take a while to get used to
31
Denture Care
bull A huge area and confusing
bull A lot of different products and makes
bull Dependent upon what the denture is made of ie type of plastic and if contains metal or ceramic or not
bull All do come with their own recommendations
bull Recommend taking dentures out and soaking overnight withhellip
bull Chlorhexadine 02 MW is safe with all (however risks staining the teeth pink) bull Steradent is also very safe as a cleaning agent
bull Toothpaste (with or without fluoride) is corroding and dentures should not be
brushed with this rather use soap and water and rinse well
bull If remaining teeth they should be brushed as normal with fluoride toothpaste
bull Dentures should be taken out at night unless strong patient preference to leave in
32
Painful mouth
I collated a local guideline on the evidence available from the sources mentioned earlier and then expert opinion from my colleagues as to the order and preferences
bull Is it mucositis (Recent chemo or radiotherapy)
bull Recommendations of a baby (soft) toothbrushes to examine a mouth and clean a mucky mouth
bull Some evidence for Benzydamine Hydrochloride 015 oral rinse (Difflam) 10-15ml rinsegargle for 20-30sec QDS Benzydamine Hydrochloride Oromucosal spray 015 QDS
bull Most common problem is battling onhellip If treatment stings stop and re-assess
bull Many other options
Thrush
It is very difficult on occasion to differentiate between a coated mouth and thrush A couple of possible useful differentiating factors (although none are certain) - open for discussion 1) plaques on softhard palate (anywhere but tongue) - more likely thrush 2) Isolated on tongue - less likely thrush 3) plaques easily cleaned away with soft toothbrush - less likely thrush 4) mucky plaques - less likely thrush With all considerations made and there could be duel pathology consider a trail of treatment in conjunction with good oral hygiene care
35
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had had an input
Re audited the ward on the 17th June
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
It also became evident there was huge overlap between xerostomia and other aspects of mouth care in particular including management of Thrush management of painful mouth and Denture care These aspects where all inseparable Issues raised and noted 1) Difficulty diagnosis of thrush ( coating) 2) Denture care (using toothbrushes masking thrushulcers) 3) Vaseline - not with oxygen 4) Brushing teeth once day 5) Unclear guidelines on painful mouth
The guideline clearly also had to incorporate and clarify these aspects
This myth is based on the National Fire Protection Associations (NFPA) 1996 edition of its Standard for Health Care Facilities which states Oil grease or other flammable contaminants shall not be used with oxygen equipment (item 8-6222) and Flammable and combustible liquids shall not be permitted within the site of intentional expulsion (item 8-6223) There is no evidence of any danger
Petroleum Jelly and Oxygen
1) Winslow EH Jacobson AF Dispelling the petroleum jelly myth AM J
Nurs199898(11)16)
2) Phippen ML Is petroleum jelly safe AM J Nurs 1999 99(8)24
3) Woodrow P Petroleum jelly myth Nurs Older People 2004 16(6) 41
Are there any adverse incidents reported in the literature There are NO case reports of adverse incidents with Vaseline applied to lips
1) Ocak I1 Raffensperger J Turkbey B Fuhrman C Lipid pneumonia secondary to
Petroleum jelly use in a patient with tympanic membrane perforation JBR-BTR
2009 Nov-Dec92(6)280-2
2) Gorospe L1 Gallego-Rivera JI Hervaacutes-Moroacuten A Exogenous lipoid pneumonia
secondary to Petroleum jelly application to the tracheostomy in a laryngectomy
patient PETCT and MR imaging findings Clin Imaging 2013 Jan-Feb37(1)163-
6 doi 101016jclinimag201202002 Epub 2012 Jun 8
Is there a fire risk
There have been some reports of surgical ignitions of
various materials such as Chlorhexidine and
Tracheostomy plastic These took place in a surgical
setting with high concentrations of oxygen and with a
clear ignition source most commonly diathermy
cauterization
NOT Vaseline
1) Gorphe P1 Sarfati B2 Janot F2 Bourgain JL3 Motamed C3 Blot F3
Temam S2 Airway fire during tracheostomy Eur Ann Otorhinolaryngol
Head Neck Dis 2014 Jun131(3)197-9 doi
101016janorl201307001 Epub 2014 Apr 1
2) Bengezi O2 Third-degree burns caused by ignition of chlorhexidine A
case report and systematic review of the literature Plast Surg (Oakv)
2014 Winter22(4)264-6 Vo A1
The Material Safety Data Sheets by Sasol demonstrate the flash
point of petroleum jelly to be around 150 degrees Celsius and an
autoignition temperature of around 320 degrees Celsius
This is way above normal environmental encounters and consistent
with plastics considered very safe
(For example Polyvinyl chloride (PVC) Flash point 250 degrees and
Ignition temp 450 degrees)
1) Sasol Material Safety Data Sheet ndash Petroleum Jelly Revision date
1142011 Created by BShamase approved by Ephraim Papo
Vaseline is flammable right
httpswwwyoutubecomwatchv=8hAUKTnHlcg
Petroleum jelly without oxygen - blow torch
httpswwwyoutubecomwatchv=yLqixjvTD7s
Petroleum jelly mixed with oxygen - blow torch
httpswwwyoutubecomwatchv=asumR-n2e6k
Oxygen Tubing
Ignition with lighter Ignition with blow torch
Petroleum jelly on
it own
Melted never ignited Melted 120 seconds to
ignite
Petroleum jelly
mixed with oxygen
10min (high flow)
Melted never ignited Melted 111 second to
ignite
Cotton wool on its
own
Ignition 3 seconds burn
time 45 seconds
Ignition instant burn time
40 seconds
Cotton wool mixed
with petroleum jelly
Ignition 11 seconds
burn time 197 seconds
Ignition instant burn time
113 seconds
Oxygen tubing Ignition 18 seconds
burn time 10 seconds
Ignition instant burn time
8 seconds
In gathering the opinions of 52 carers and nursing colleagues in
Bedford Hospital Addenbrooks and Sue Ryder Hospice in relation
to the use of petroleum Jelly with oxygen the following concerns
were highlighted
1) Risk of blame if anything untoward happens
2) Potential to be told off by seniors
3) Must not challenge policy even if I personally disagree
4) The change would not be sustained by my colleagues
A lot of resistancehellip Why
There is no evidence that Vaseline is superior to aqueous products at maintaining moisture in the mouth Howeverhellip In my expereince (and I would argue the vast majority of carers and nurses) would use vaseline for themselves and think its superior to aquos products What do you think
28
Brushing teeth
1 Hale KJ American Academy of Pediatrics Section on Pediatric
Dentistry Oral health risk assessment timing and establishment
of the dental home Pediatrics 2003 1111113
2 Beltraacuten-Aguilar ED Barker LK Canto MT et al Surveillance for
dental caries dental sealants tooth retention edentulism and
enamel fluorosis--United States 1988-1994 and 1999-2002
MMWR Surveill Summ 2005 541
3 NIDR the prevalence of dental caries in United States children
The National Caries Prevalence Survey 1979-1989 NIH
Publication 82-2245 National Instutute of Dental Research
National Caries Program 1981
4 Brunelle JA Oral health of United States children The National
Survey of Dental Caries in US School Children 1986-1987 NIH
Publication 9-2247 National Institute of Dental Research
Epidemiology and Disease Prevention Program 1989
5 Kelly JE Harvey CR Basic data on dental examination findings
of persons 1-74 years United States 1971-1974 Vital Health
Stat 11 1979 1
There is clear consensus throughout dental literature regarding the importance of regular brushing with a fluoride toothpaste - generally recommending after every meal
Are we brushing teeth NI Hospice I was assured we were brushing teeth at least twice day So I measured ithellip A single night 7 out of the 13 patients got their teeth brushed twicendash NI hospice St Johns Hospice Sue Ryder That would never happen to us we definitely do it twice day So I measured ithellip 13 out of 20 patients got their teeth brushed twice - St Johns Hospice Severn Hospice Community Of also interesting note do not rinse your mouth afterwards to allow fluoride to act
Non foaming toothpaste
Sodium laureth sulfate (SLS) or sodium lauryl ether sulfate (SLES) is a detergent and surfactant found in many personal care products (soaps shampoos toothpastes etc) bull It makes the toothpaste froth
bull SLS Free toothpastes are available
bull Make sure they are fluoride based
bull Less drying than normal toothpaste
bull Take a while to get used to
31
Denture Care
bull A huge area and confusing
bull A lot of different products and makes
bull Dependent upon what the denture is made of ie type of plastic and if contains metal or ceramic or not
bull All do come with their own recommendations
bull Recommend taking dentures out and soaking overnight withhellip
bull Chlorhexadine 02 MW is safe with all (however risks staining the teeth pink) bull Steradent is also very safe as a cleaning agent
bull Toothpaste (with or without fluoride) is corroding and dentures should not be
brushed with this rather use soap and water and rinse well
bull If remaining teeth they should be brushed as normal with fluoride toothpaste
bull Dentures should be taken out at night unless strong patient preference to leave in
32
Painful mouth
I collated a local guideline on the evidence available from the sources mentioned earlier and then expert opinion from my colleagues as to the order and preferences
bull Is it mucositis (Recent chemo or radiotherapy)
bull Recommendations of a baby (soft) toothbrushes to examine a mouth and clean a mucky mouth
bull Some evidence for Benzydamine Hydrochloride 015 oral rinse (Difflam) 10-15ml rinsegargle for 20-30sec QDS Benzydamine Hydrochloride Oromucosal spray 015 QDS
bull Most common problem is battling onhellip If treatment stings stop and re-assess
bull Many other options
Thrush
It is very difficult on occasion to differentiate between a coated mouth and thrush A couple of possible useful differentiating factors (although none are certain) - open for discussion 1) plaques on softhard palate (anywhere but tongue) - more likely thrush 2) Isolated on tongue - less likely thrush 3) plaques easily cleaned away with soft toothbrush - less likely thrush 4) mucky plaques - less likely thrush With all considerations made and there could be duel pathology consider a trail of treatment in conjunction with good oral hygiene care
35
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had had an input
Re audited the ward on the 17th June
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
This myth is based on the National Fire Protection Associations (NFPA) 1996 edition of its Standard for Health Care Facilities which states Oil grease or other flammable contaminants shall not be used with oxygen equipment (item 8-6222) and Flammable and combustible liquids shall not be permitted within the site of intentional expulsion (item 8-6223) There is no evidence of any danger
Petroleum Jelly and Oxygen
1) Winslow EH Jacobson AF Dispelling the petroleum jelly myth AM J
Nurs199898(11)16)
2) Phippen ML Is petroleum jelly safe AM J Nurs 1999 99(8)24
3) Woodrow P Petroleum jelly myth Nurs Older People 2004 16(6) 41
Are there any adverse incidents reported in the literature There are NO case reports of adverse incidents with Vaseline applied to lips
1) Ocak I1 Raffensperger J Turkbey B Fuhrman C Lipid pneumonia secondary to
Petroleum jelly use in a patient with tympanic membrane perforation JBR-BTR
2009 Nov-Dec92(6)280-2
2) Gorospe L1 Gallego-Rivera JI Hervaacutes-Moroacuten A Exogenous lipoid pneumonia
secondary to Petroleum jelly application to the tracheostomy in a laryngectomy
patient PETCT and MR imaging findings Clin Imaging 2013 Jan-Feb37(1)163-
6 doi 101016jclinimag201202002 Epub 2012 Jun 8
Is there a fire risk
There have been some reports of surgical ignitions of
various materials such as Chlorhexidine and
Tracheostomy plastic These took place in a surgical
setting with high concentrations of oxygen and with a
clear ignition source most commonly diathermy
cauterization
NOT Vaseline
1) Gorphe P1 Sarfati B2 Janot F2 Bourgain JL3 Motamed C3 Blot F3
Temam S2 Airway fire during tracheostomy Eur Ann Otorhinolaryngol
Head Neck Dis 2014 Jun131(3)197-9 doi
101016janorl201307001 Epub 2014 Apr 1
2) Bengezi O2 Third-degree burns caused by ignition of chlorhexidine A
case report and systematic review of the literature Plast Surg (Oakv)
2014 Winter22(4)264-6 Vo A1
The Material Safety Data Sheets by Sasol demonstrate the flash
point of petroleum jelly to be around 150 degrees Celsius and an
autoignition temperature of around 320 degrees Celsius
This is way above normal environmental encounters and consistent
with plastics considered very safe
(For example Polyvinyl chloride (PVC) Flash point 250 degrees and
Ignition temp 450 degrees)
1) Sasol Material Safety Data Sheet ndash Petroleum Jelly Revision date
1142011 Created by BShamase approved by Ephraim Papo
Vaseline is flammable right
httpswwwyoutubecomwatchv=8hAUKTnHlcg
Petroleum jelly without oxygen - blow torch
httpswwwyoutubecomwatchv=yLqixjvTD7s
Petroleum jelly mixed with oxygen - blow torch
httpswwwyoutubecomwatchv=asumR-n2e6k
Oxygen Tubing
Ignition with lighter Ignition with blow torch
Petroleum jelly on
it own
Melted never ignited Melted 120 seconds to
ignite
Petroleum jelly
mixed with oxygen
10min (high flow)
Melted never ignited Melted 111 second to
ignite
Cotton wool on its
own
Ignition 3 seconds burn
time 45 seconds
Ignition instant burn time
40 seconds
Cotton wool mixed
with petroleum jelly
Ignition 11 seconds
burn time 197 seconds
Ignition instant burn time
113 seconds
Oxygen tubing Ignition 18 seconds
burn time 10 seconds
Ignition instant burn time
8 seconds
In gathering the opinions of 52 carers and nursing colleagues in
Bedford Hospital Addenbrooks and Sue Ryder Hospice in relation
to the use of petroleum Jelly with oxygen the following concerns
were highlighted
1) Risk of blame if anything untoward happens
2) Potential to be told off by seniors
3) Must not challenge policy even if I personally disagree
4) The change would not be sustained by my colleagues
A lot of resistancehellip Why
There is no evidence that Vaseline is superior to aqueous products at maintaining moisture in the mouth Howeverhellip In my expereince (and I would argue the vast majority of carers and nurses) would use vaseline for themselves and think its superior to aquos products What do you think
28
Brushing teeth
1 Hale KJ American Academy of Pediatrics Section on Pediatric
Dentistry Oral health risk assessment timing and establishment
of the dental home Pediatrics 2003 1111113
2 Beltraacuten-Aguilar ED Barker LK Canto MT et al Surveillance for
dental caries dental sealants tooth retention edentulism and
enamel fluorosis--United States 1988-1994 and 1999-2002
MMWR Surveill Summ 2005 541
3 NIDR the prevalence of dental caries in United States children
The National Caries Prevalence Survey 1979-1989 NIH
Publication 82-2245 National Instutute of Dental Research
National Caries Program 1981
4 Brunelle JA Oral health of United States children The National
Survey of Dental Caries in US School Children 1986-1987 NIH
Publication 9-2247 National Institute of Dental Research
Epidemiology and Disease Prevention Program 1989
5 Kelly JE Harvey CR Basic data on dental examination findings
of persons 1-74 years United States 1971-1974 Vital Health
Stat 11 1979 1
There is clear consensus throughout dental literature regarding the importance of regular brushing with a fluoride toothpaste - generally recommending after every meal
Are we brushing teeth NI Hospice I was assured we were brushing teeth at least twice day So I measured ithellip A single night 7 out of the 13 patients got their teeth brushed twicendash NI hospice St Johns Hospice Sue Ryder That would never happen to us we definitely do it twice day So I measured ithellip 13 out of 20 patients got their teeth brushed twice - St Johns Hospice Severn Hospice Community Of also interesting note do not rinse your mouth afterwards to allow fluoride to act
Non foaming toothpaste
Sodium laureth sulfate (SLS) or sodium lauryl ether sulfate (SLES) is a detergent and surfactant found in many personal care products (soaps shampoos toothpastes etc) bull It makes the toothpaste froth
bull SLS Free toothpastes are available
bull Make sure they are fluoride based
bull Less drying than normal toothpaste
bull Take a while to get used to
31
Denture Care
bull A huge area and confusing
bull A lot of different products and makes
bull Dependent upon what the denture is made of ie type of plastic and if contains metal or ceramic or not
bull All do come with their own recommendations
bull Recommend taking dentures out and soaking overnight withhellip
bull Chlorhexadine 02 MW is safe with all (however risks staining the teeth pink) bull Steradent is also very safe as a cleaning agent
bull Toothpaste (with or without fluoride) is corroding and dentures should not be
brushed with this rather use soap and water and rinse well
bull If remaining teeth they should be brushed as normal with fluoride toothpaste
bull Dentures should be taken out at night unless strong patient preference to leave in
32
Painful mouth
I collated a local guideline on the evidence available from the sources mentioned earlier and then expert opinion from my colleagues as to the order and preferences
bull Is it mucositis (Recent chemo or radiotherapy)
bull Recommendations of a baby (soft) toothbrushes to examine a mouth and clean a mucky mouth
bull Some evidence for Benzydamine Hydrochloride 015 oral rinse (Difflam) 10-15ml rinsegargle for 20-30sec QDS Benzydamine Hydrochloride Oromucosal spray 015 QDS
bull Most common problem is battling onhellip If treatment stings stop and re-assess
bull Many other options
Thrush
It is very difficult on occasion to differentiate between a coated mouth and thrush A couple of possible useful differentiating factors (although none are certain) - open for discussion 1) plaques on softhard palate (anywhere but tongue) - more likely thrush 2) Isolated on tongue - less likely thrush 3) plaques easily cleaned away with soft toothbrush - less likely thrush 4) mucky plaques - less likely thrush With all considerations made and there could be duel pathology consider a trail of treatment in conjunction with good oral hygiene care
35
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had had an input
Re audited the ward on the 17th June
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
Are there any adverse incidents reported in the literature There are NO case reports of adverse incidents with Vaseline applied to lips
1) Ocak I1 Raffensperger J Turkbey B Fuhrman C Lipid pneumonia secondary to
Petroleum jelly use in a patient with tympanic membrane perforation JBR-BTR
2009 Nov-Dec92(6)280-2
2) Gorospe L1 Gallego-Rivera JI Hervaacutes-Moroacuten A Exogenous lipoid pneumonia
secondary to Petroleum jelly application to the tracheostomy in a laryngectomy
patient PETCT and MR imaging findings Clin Imaging 2013 Jan-Feb37(1)163-
6 doi 101016jclinimag201202002 Epub 2012 Jun 8
Is there a fire risk
There have been some reports of surgical ignitions of
various materials such as Chlorhexidine and
Tracheostomy plastic These took place in a surgical
setting with high concentrations of oxygen and with a
clear ignition source most commonly diathermy
cauterization
NOT Vaseline
1) Gorphe P1 Sarfati B2 Janot F2 Bourgain JL3 Motamed C3 Blot F3
Temam S2 Airway fire during tracheostomy Eur Ann Otorhinolaryngol
Head Neck Dis 2014 Jun131(3)197-9 doi
101016janorl201307001 Epub 2014 Apr 1
2) Bengezi O2 Third-degree burns caused by ignition of chlorhexidine A
case report and systematic review of the literature Plast Surg (Oakv)
2014 Winter22(4)264-6 Vo A1
The Material Safety Data Sheets by Sasol demonstrate the flash
point of petroleum jelly to be around 150 degrees Celsius and an
autoignition temperature of around 320 degrees Celsius
This is way above normal environmental encounters and consistent
with plastics considered very safe
(For example Polyvinyl chloride (PVC) Flash point 250 degrees and
Ignition temp 450 degrees)
1) Sasol Material Safety Data Sheet ndash Petroleum Jelly Revision date
1142011 Created by BShamase approved by Ephraim Papo
Vaseline is flammable right
httpswwwyoutubecomwatchv=8hAUKTnHlcg
Petroleum jelly without oxygen - blow torch
httpswwwyoutubecomwatchv=yLqixjvTD7s
Petroleum jelly mixed with oxygen - blow torch
httpswwwyoutubecomwatchv=asumR-n2e6k
Oxygen Tubing
Ignition with lighter Ignition with blow torch
Petroleum jelly on
it own
Melted never ignited Melted 120 seconds to
ignite
Petroleum jelly
mixed with oxygen
10min (high flow)
Melted never ignited Melted 111 second to
ignite
Cotton wool on its
own
Ignition 3 seconds burn
time 45 seconds
Ignition instant burn time
40 seconds
Cotton wool mixed
with petroleum jelly
Ignition 11 seconds
burn time 197 seconds
Ignition instant burn time
113 seconds
Oxygen tubing Ignition 18 seconds
burn time 10 seconds
Ignition instant burn time
8 seconds
In gathering the opinions of 52 carers and nursing colleagues in
Bedford Hospital Addenbrooks and Sue Ryder Hospice in relation
to the use of petroleum Jelly with oxygen the following concerns
were highlighted
1) Risk of blame if anything untoward happens
2) Potential to be told off by seniors
3) Must not challenge policy even if I personally disagree
4) The change would not be sustained by my colleagues
A lot of resistancehellip Why
There is no evidence that Vaseline is superior to aqueous products at maintaining moisture in the mouth Howeverhellip In my expereince (and I would argue the vast majority of carers and nurses) would use vaseline for themselves and think its superior to aquos products What do you think
28
Brushing teeth
1 Hale KJ American Academy of Pediatrics Section on Pediatric
Dentistry Oral health risk assessment timing and establishment
of the dental home Pediatrics 2003 1111113
2 Beltraacuten-Aguilar ED Barker LK Canto MT et al Surveillance for
dental caries dental sealants tooth retention edentulism and
enamel fluorosis--United States 1988-1994 and 1999-2002
MMWR Surveill Summ 2005 541
3 NIDR the prevalence of dental caries in United States children
The National Caries Prevalence Survey 1979-1989 NIH
Publication 82-2245 National Instutute of Dental Research
National Caries Program 1981
4 Brunelle JA Oral health of United States children The National
Survey of Dental Caries in US School Children 1986-1987 NIH
Publication 9-2247 National Institute of Dental Research
Epidemiology and Disease Prevention Program 1989
5 Kelly JE Harvey CR Basic data on dental examination findings
of persons 1-74 years United States 1971-1974 Vital Health
Stat 11 1979 1
There is clear consensus throughout dental literature regarding the importance of regular brushing with a fluoride toothpaste - generally recommending after every meal
Are we brushing teeth NI Hospice I was assured we were brushing teeth at least twice day So I measured ithellip A single night 7 out of the 13 patients got their teeth brushed twicendash NI hospice St Johns Hospice Sue Ryder That would never happen to us we definitely do it twice day So I measured ithellip 13 out of 20 patients got their teeth brushed twice - St Johns Hospice Severn Hospice Community Of also interesting note do not rinse your mouth afterwards to allow fluoride to act
Non foaming toothpaste
Sodium laureth sulfate (SLS) or sodium lauryl ether sulfate (SLES) is a detergent and surfactant found in many personal care products (soaps shampoos toothpastes etc) bull It makes the toothpaste froth
bull SLS Free toothpastes are available
bull Make sure they are fluoride based
bull Less drying than normal toothpaste
bull Take a while to get used to
31
Denture Care
bull A huge area and confusing
bull A lot of different products and makes
bull Dependent upon what the denture is made of ie type of plastic and if contains metal or ceramic or not
bull All do come with their own recommendations
bull Recommend taking dentures out and soaking overnight withhellip
bull Chlorhexadine 02 MW is safe with all (however risks staining the teeth pink) bull Steradent is also very safe as a cleaning agent
bull Toothpaste (with or without fluoride) is corroding and dentures should not be
brushed with this rather use soap and water and rinse well
bull If remaining teeth they should be brushed as normal with fluoride toothpaste
bull Dentures should be taken out at night unless strong patient preference to leave in
32
Painful mouth
I collated a local guideline on the evidence available from the sources mentioned earlier and then expert opinion from my colleagues as to the order and preferences
bull Is it mucositis (Recent chemo or radiotherapy)
bull Recommendations of a baby (soft) toothbrushes to examine a mouth and clean a mucky mouth
bull Some evidence for Benzydamine Hydrochloride 015 oral rinse (Difflam) 10-15ml rinsegargle for 20-30sec QDS Benzydamine Hydrochloride Oromucosal spray 015 QDS
bull Most common problem is battling onhellip If treatment stings stop and re-assess
bull Many other options
Thrush
It is very difficult on occasion to differentiate between a coated mouth and thrush A couple of possible useful differentiating factors (although none are certain) - open for discussion 1) plaques on softhard palate (anywhere but tongue) - more likely thrush 2) Isolated on tongue - less likely thrush 3) plaques easily cleaned away with soft toothbrush - less likely thrush 4) mucky plaques - less likely thrush With all considerations made and there could be duel pathology consider a trail of treatment in conjunction with good oral hygiene care
35
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had had an input
Re audited the ward on the 17th June
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
Is there a fire risk
There have been some reports of surgical ignitions of
various materials such as Chlorhexidine and
Tracheostomy plastic These took place in a surgical
setting with high concentrations of oxygen and with a
clear ignition source most commonly diathermy
cauterization
NOT Vaseline
1) Gorphe P1 Sarfati B2 Janot F2 Bourgain JL3 Motamed C3 Blot F3
Temam S2 Airway fire during tracheostomy Eur Ann Otorhinolaryngol
Head Neck Dis 2014 Jun131(3)197-9 doi
101016janorl201307001 Epub 2014 Apr 1
2) Bengezi O2 Third-degree burns caused by ignition of chlorhexidine A
case report and systematic review of the literature Plast Surg (Oakv)
2014 Winter22(4)264-6 Vo A1
The Material Safety Data Sheets by Sasol demonstrate the flash
point of petroleum jelly to be around 150 degrees Celsius and an
autoignition temperature of around 320 degrees Celsius
This is way above normal environmental encounters and consistent
with plastics considered very safe
(For example Polyvinyl chloride (PVC) Flash point 250 degrees and
Ignition temp 450 degrees)
1) Sasol Material Safety Data Sheet ndash Petroleum Jelly Revision date
1142011 Created by BShamase approved by Ephraim Papo
Vaseline is flammable right
httpswwwyoutubecomwatchv=8hAUKTnHlcg
Petroleum jelly without oxygen - blow torch
httpswwwyoutubecomwatchv=yLqixjvTD7s
Petroleum jelly mixed with oxygen - blow torch
httpswwwyoutubecomwatchv=asumR-n2e6k
Oxygen Tubing
Ignition with lighter Ignition with blow torch
Petroleum jelly on
it own
Melted never ignited Melted 120 seconds to
ignite
Petroleum jelly
mixed with oxygen
10min (high flow)
Melted never ignited Melted 111 second to
ignite
Cotton wool on its
own
Ignition 3 seconds burn
time 45 seconds
Ignition instant burn time
40 seconds
Cotton wool mixed
with petroleum jelly
Ignition 11 seconds
burn time 197 seconds
Ignition instant burn time
113 seconds
Oxygen tubing Ignition 18 seconds
burn time 10 seconds
Ignition instant burn time
8 seconds
In gathering the opinions of 52 carers and nursing colleagues in
Bedford Hospital Addenbrooks and Sue Ryder Hospice in relation
to the use of petroleum Jelly with oxygen the following concerns
were highlighted
1) Risk of blame if anything untoward happens
2) Potential to be told off by seniors
3) Must not challenge policy even if I personally disagree
4) The change would not be sustained by my colleagues
A lot of resistancehellip Why
There is no evidence that Vaseline is superior to aqueous products at maintaining moisture in the mouth Howeverhellip In my expereince (and I would argue the vast majority of carers and nurses) would use vaseline for themselves and think its superior to aquos products What do you think
28
Brushing teeth
1 Hale KJ American Academy of Pediatrics Section on Pediatric
Dentistry Oral health risk assessment timing and establishment
of the dental home Pediatrics 2003 1111113
2 Beltraacuten-Aguilar ED Barker LK Canto MT et al Surveillance for
dental caries dental sealants tooth retention edentulism and
enamel fluorosis--United States 1988-1994 and 1999-2002
MMWR Surveill Summ 2005 541
3 NIDR the prevalence of dental caries in United States children
The National Caries Prevalence Survey 1979-1989 NIH
Publication 82-2245 National Instutute of Dental Research
National Caries Program 1981
4 Brunelle JA Oral health of United States children The National
Survey of Dental Caries in US School Children 1986-1987 NIH
Publication 9-2247 National Institute of Dental Research
Epidemiology and Disease Prevention Program 1989
5 Kelly JE Harvey CR Basic data on dental examination findings
of persons 1-74 years United States 1971-1974 Vital Health
Stat 11 1979 1
There is clear consensus throughout dental literature regarding the importance of regular brushing with a fluoride toothpaste - generally recommending after every meal
Are we brushing teeth NI Hospice I was assured we were brushing teeth at least twice day So I measured ithellip A single night 7 out of the 13 patients got their teeth brushed twicendash NI hospice St Johns Hospice Sue Ryder That would never happen to us we definitely do it twice day So I measured ithellip 13 out of 20 patients got their teeth brushed twice - St Johns Hospice Severn Hospice Community Of also interesting note do not rinse your mouth afterwards to allow fluoride to act
Non foaming toothpaste
Sodium laureth sulfate (SLS) or sodium lauryl ether sulfate (SLES) is a detergent and surfactant found in many personal care products (soaps shampoos toothpastes etc) bull It makes the toothpaste froth
bull SLS Free toothpastes are available
bull Make sure they are fluoride based
bull Less drying than normal toothpaste
bull Take a while to get used to
31
Denture Care
bull A huge area and confusing
bull A lot of different products and makes
bull Dependent upon what the denture is made of ie type of plastic and if contains metal or ceramic or not
bull All do come with their own recommendations
bull Recommend taking dentures out and soaking overnight withhellip
bull Chlorhexadine 02 MW is safe with all (however risks staining the teeth pink) bull Steradent is also very safe as a cleaning agent
bull Toothpaste (with or without fluoride) is corroding and dentures should not be
brushed with this rather use soap and water and rinse well
bull If remaining teeth they should be brushed as normal with fluoride toothpaste
bull Dentures should be taken out at night unless strong patient preference to leave in
32
Painful mouth
I collated a local guideline on the evidence available from the sources mentioned earlier and then expert opinion from my colleagues as to the order and preferences
bull Is it mucositis (Recent chemo or radiotherapy)
bull Recommendations of a baby (soft) toothbrushes to examine a mouth and clean a mucky mouth
bull Some evidence for Benzydamine Hydrochloride 015 oral rinse (Difflam) 10-15ml rinsegargle for 20-30sec QDS Benzydamine Hydrochloride Oromucosal spray 015 QDS
bull Most common problem is battling onhellip If treatment stings stop and re-assess
bull Many other options
Thrush
It is very difficult on occasion to differentiate between a coated mouth and thrush A couple of possible useful differentiating factors (although none are certain) - open for discussion 1) plaques on softhard palate (anywhere but tongue) - more likely thrush 2) Isolated on tongue - less likely thrush 3) plaques easily cleaned away with soft toothbrush - less likely thrush 4) mucky plaques - less likely thrush With all considerations made and there could be duel pathology consider a trail of treatment in conjunction with good oral hygiene care
35
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had had an input
Re audited the ward on the 17th June
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
The Material Safety Data Sheets by Sasol demonstrate the flash
point of petroleum jelly to be around 150 degrees Celsius and an
autoignition temperature of around 320 degrees Celsius
This is way above normal environmental encounters and consistent
with plastics considered very safe
(For example Polyvinyl chloride (PVC) Flash point 250 degrees and
Ignition temp 450 degrees)
1) Sasol Material Safety Data Sheet ndash Petroleum Jelly Revision date
1142011 Created by BShamase approved by Ephraim Papo
Vaseline is flammable right
httpswwwyoutubecomwatchv=8hAUKTnHlcg
Petroleum jelly without oxygen - blow torch
httpswwwyoutubecomwatchv=yLqixjvTD7s
Petroleum jelly mixed with oxygen - blow torch
httpswwwyoutubecomwatchv=asumR-n2e6k
Oxygen Tubing
Ignition with lighter Ignition with blow torch
Petroleum jelly on
it own
Melted never ignited Melted 120 seconds to
ignite
Petroleum jelly
mixed with oxygen
10min (high flow)
Melted never ignited Melted 111 second to
ignite
Cotton wool on its
own
Ignition 3 seconds burn
time 45 seconds
Ignition instant burn time
40 seconds
Cotton wool mixed
with petroleum jelly
Ignition 11 seconds
burn time 197 seconds
Ignition instant burn time
113 seconds
Oxygen tubing Ignition 18 seconds
burn time 10 seconds
Ignition instant burn time
8 seconds
In gathering the opinions of 52 carers and nursing colleagues in
Bedford Hospital Addenbrooks and Sue Ryder Hospice in relation
to the use of petroleum Jelly with oxygen the following concerns
were highlighted
1) Risk of blame if anything untoward happens
2) Potential to be told off by seniors
3) Must not challenge policy even if I personally disagree
4) The change would not be sustained by my colleagues
A lot of resistancehellip Why
There is no evidence that Vaseline is superior to aqueous products at maintaining moisture in the mouth Howeverhellip In my expereince (and I would argue the vast majority of carers and nurses) would use vaseline for themselves and think its superior to aquos products What do you think
28
Brushing teeth
1 Hale KJ American Academy of Pediatrics Section on Pediatric
Dentistry Oral health risk assessment timing and establishment
of the dental home Pediatrics 2003 1111113
2 Beltraacuten-Aguilar ED Barker LK Canto MT et al Surveillance for
dental caries dental sealants tooth retention edentulism and
enamel fluorosis--United States 1988-1994 and 1999-2002
MMWR Surveill Summ 2005 541
3 NIDR the prevalence of dental caries in United States children
The National Caries Prevalence Survey 1979-1989 NIH
Publication 82-2245 National Instutute of Dental Research
National Caries Program 1981
4 Brunelle JA Oral health of United States children The National
Survey of Dental Caries in US School Children 1986-1987 NIH
Publication 9-2247 National Institute of Dental Research
Epidemiology and Disease Prevention Program 1989
5 Kelly JE Harvey CR Basic data on dental examination findings
of persons 1-74 years United States 1971-1974 Vital Health
Stat 11 1979 1
There is clear consensus throughout dental literature regarding the importance of regular brushing with a fluoride toothpaste - generally recommending after every meal
Are we brushing teeth NI Hospice I was assured we were brushing teeth at least twice day So I measured ithellip A single night 7 out of the 13 patients got their teeth brushed twicendash NI hospice St Johns Hospice Sue Ryder That would never happen to us we definitely do it twice day So I measured ithellip 13 out of 20 patients got their teeth brushed twice - St Johns Hospice Severn Hospice Community Of also interesting note do not rinse your mouth afterwards to allow fluoride to act
Non foaming toothpaste
Sodium laureth sulfate (SLS) or sodium lauryl ether sulfate (SLES) is a detergent and surfactant found in many personal care products (soaps shampoos toothpastes etc) bull It makes the toothpaste froth
bull SLS Free toothpastes are available
bull Make sure they are fluoride based
bull Less drying than normal toothpaste
bull Take a while to get used to
31
Denture Care
bull A huge area and confusing
bull A lot of different products and makes
bull Dependent upon what the denture is made of ie type of plastic and if contains metal or ceramic or not
bull All do come with their own recommendations
bull Recommend taking dentures out and soaking overnight withhellip
bull Chlorhexadine 02 MW is safe with all (however risks staining the teeth pink) bull Steradent is also very safe as a cleaning agent
bull Toothpaste (with or without fluoride) is corroding and dentures should not be
brushed with this rather use soap and water and rinse well
bull If remaining teeth they should be brushed as normal with fluoride toothpaste
bull Dentures should be taken out at night unless strong patient preference to leave in
32
Painful mouth
I collated a local guideline on the evidence available from the sources mentioned earlier and then expert opinion from my colleagues as to the order and preferences
bull Is it mucositis (Recent chemo or radiotherapy)
bull Recommendations of a baby (soft) toothbrushes to examine a mouth and clean a mucky mouth
bull Some evidence for Benzydamine Hydrochloride 015 oral rinse (Difflam) 10-15ml rinsegargle for 20-30sec QDS Benzydamine Hydrochloride Oromucosal spray 015 QDS
bull Most common problem is battling onhellip If treatment stings stop and re-assess
bull Many other options
Thrush
It is very difficult on occasion to differentiate between a coated mouth and thrush A couple of possible useful differentiating factors (although none are certain) - open for discussion 1) plaques on softhard palate (anywhere but tongue) - more likely thrush 2) Isolated on tongue - less likely thrush 3) plaques easily cleaned away with soft toothbrush - less likely thrush 4) mucky plaques - less likely thrush With all considerations made and there could be duel pathology consider a trail of treatment in conjunction with good oral hygiene care
35
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had had an input
Re audited the ward on the 17th June
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
httpswwwyoutubecomwatchv=8hAUKTnHlcg
Petroleum jelly without oxygen - blow torch
httpswwwyoutubecomwatchv=yLqixjvTD7s
Petroleum jelly mixed with oxygen - blow torch
httpswwwyoutubecomwatchv=asumR-n2e6k
Oxygen Tubing
Ignition with lighter Ignition with blow torch
Petroleum jelly on
it own
Melted never ignited Melted 120 seconds to
ignite
Petroleum jelly
mixed with oxygen
10min (high flow)
Melted never ignited Melted 111 second to
ignite
Cotton wool on its
own
Ignition 3 seconds burn
time 45 seconds
Ignition instant burn time
40 seconds
Cotton wool mixed
with petroleum jelly
Ignition 11 seconds
burn time 197 seconds
Ignition instant burn time
113 seconds
Oxygen tubing Ignition 18 seconds
burn time 10 seconds
Ignition instant burn time
8 seconds
In gathering the opinions of 52 carers and nursing colleagues in
Bedford Hospital Addenbrooks and Sue Ryder Hospice in relation
to the use of petroleum Jelly with oxygen the following concerns
were highlighted
1) Risk of blame if anything untoward happens
2) Potential to be told off by seniors
3) Must not challenge policy even if I personally disagree
4) The change would not be sustained by my colleagues
A lot of resistancehellip Why
There is no evidence that Vaseline is superior to aqueous products at maintaining moisture in the mouth Howeverhellip In my expereince (and I would argue the vast majority of carers and nurses) would use vaseline for themselves and think its superior to aquos products What do you think
28
Brushing teeth
1 Hale KJ American Academy of Pediatrics Section on Pediatric
Dentistry Oral health risk assessment timing and establishment
of the dental home Pediatrics 2003 1111113
2 Beltraacuten-Aguilar ED Barker LK Canto MT et al Surveillance for
dental caries dental sealants tooth retention edentulism and
enamel fluorosis--United States 1988-1994 and 1999-2002
MMWR Surveill Summ 2005 541
3 NIDR the prevalence of dental caries in United States children
The National Caries Prevalence Survey 1979-1989 NIH
Publication 82-2245 National Instutute of Dental Research
National Caries Program 1981
4 Brunelle JA Oral health of United States children The National
Survey of Dental Caries in US School Children 1986-1987 NIH
Publication 9-2247 National Institute of Dental Research
Epidemiology and Disease Prevention Program 1989
5 Kelly JE Harvey CR Basic data on dental examination findings
of persons 1-74 years United States 1971-1974 Vital Health
Stat 11 1979 1
There is clear consensus throughout dental literature regarding the importance of regular brushing with a fluoride toothpaste - generally recommending after every meal
Are we brushing teeth NI Hospice I was assured we were brushing teeth at least twice day So I measured ithellip A single night 7 out of the 13 patients got their teeth brushed twicendash NI hospice St Johns Hospice Sue Ryder That would never happen to us we definitely do it twice day So I measured ithellip 13 out of 20 patients got their teeth brushed twice - St Johns Hospice Severn Hospice Community Of also interesting note do not rinse your mouth afterwards to allow fluoride to act
Non foaming toothpaste
Sodium laureth sulfate (SLS) or sodium lauryl ether sulfate (SLES) is a detergent and surfactant found in many personal care products (soaps shampoos toothpastes etc) bull It makes the toothpaste froth
bull SLS Free toothpastes are available
bull Make sure they are fluoride based
bull Less drying than normal toothpaste
bull Take a while to get used to
31
Denture Care
bull A huge area and confusing
bull A lot of different products and makes
bull Dependent upon what the denture is made of ie type of plastic and if contains metal or ceramic or not
bull All do come with their own recommendations
bull Recommend taking dentures out and soaking overnight withhellip
bull Chlorhexadine 02 MW is safe with all (however risks staining the teeth pink) bull Steradent is also very safe as a cleaning agent
bull Toothpaste (with or without fluoride) is corroding and dentures should not be
brushed with this rather use soap and water and rinse well
bull If remaining teeth they should be brushed as normal with fluoride toothpaste
bull Dentures should be taken out at night unless strong patient preference to leave in
32
Painful mouth
I collated a local guideline on the evidence available from the sources mentioned earlier and then expert opinion from my colleagues as to the order and preferences
bull Is it mucositis (Recent chemo or radiotherapy)
bull Recommendations of a baby (soft) toothbrushes to examine a mouth and clean a mucky mouth
bull Some evidence for Benzydamine Hydrochloride 015 oral rinse (Difflam) 10-15ml rinsegargle for 20-30sec QDS Benzydamine Hydrochloride Oromucosal spray 015 QDS
bull Most common problem is battling onhellip If treatment stings stop and re-assess
bull Many other options
Thrush
It is very difficult on occasion to differentiate between a coated mouth and thrush A couple of possible useful differentiating factors (although none are certain) - open for discussion 1) plaques on softhard palate (anywhere but tongue) - more likely thrush 2) Isolated on tongue - less likely thrush 3) plaques easily cleaned away with soft toothbrush - less likely thrush 4) mucky plaques - less likely thrush With all considerations made and there could be duel pathology consider a trail of treatment in conjunction with good oral hygiene care
35
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had had an input
Re audited the ward on the 17th June
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
httpswwwyoutubecomwatchv=yLqixjvTD7s
Petroleum jelly mixed with oxygen - blow torch
httpswwwyoutubecomwatchv=asumR-n2e6k
Oxygen Tubing
Ignition with lighter Ignition with blow torch
Petroleum jelly on
it own
Melted never ignited Melted 120 seconds to
ignite
Petroleum jelly
mixed with oxygen
10min (high flow)
Melted never ignited Melted 111 second to
ignite
Cotton wool on its
own
Ignition 3 seconds burn
time 45 seconds
Ignition instant burn time
40 seconds
Cotton wool mixed
with petroleum jelly
Ignition 11 seconds
burn time 197 seconds
Ignition instant burn time
113 seconds
Oxygen tubing Ignition 18 seconds
burn time 10 seconds
Ignition instant burn time
8 seconds
In gathering the opinions of 52 carers and nursing colleagues in
Bedford Hospital Addenbrooks and Sue Ryder Hospice in relation
to the use of petroleum Jelly with oxygen the following concerns
were highlighted
1) Risk of blame if anything untoward happens
2) Potential to be told off by seniors
3) Must not challenge policy even if I personally disagree
4) The change would not be sustained by my colleagues
A lot of resistancehellip Why
There is no evidence that Vaseline is superior to aqueous products at maintaining moisture in the mouth Howeverhellip In my expereince (and I would argue the vast majority of carers and nurses) would use vaseline for themselves and think its superior to aquos products What do you think
28
Brushing teeth
1 Hale KJ American Academy of Pediatrics Section on Pediatric
Dentistry Oral health risk assessment timing and establishment
of the dental home Pediatrics 2003 1111113
2 Beltraacuten-Aguilar ED Barker LK Canto MT et al Surveillance for
dental caries dental sealants tooth retention edentulism and
enamel fluorosis--United States 1988-1994 and 1999-2002
MMWR Surveill Summ 2005 541
3 NIDR the prevalence of dental caries in United States children
The National Caries Prevalence Survey 1979-1989 NIH
Publication 82-2245 National Instutute of Dental Research
National Caries Program 1981
4 Brunelle JA Oral health of United States children The National
Survey of Dental Caries in US School Children 1986-1987 NIH
Publication 9-2247 National Institute of Dental Research
Epidemiology and Disease Prevention Program 1989
5 Kelly JE Harvey CR Basic data on dental examination findings
of persons 1-74 years United States 1971-1974 Vital Health
Stat 11 1979 1
There is clear consensus throughout dental literature regarding the importance of regular brushing with a fluoride toothpaste - generally recommending after every meal
Are we brushing teeth NI Hospice I was assured we were brushing teeth at least twice day So I measured ithellip A single night 7 out of the 13 patients got their teeth brushed twicendash NI hospice St Johns Hospice Sue Ryder That would never happen to us we definitely do it twice day So I measured ithellip 13 out of 20 patients got their teeth brushed twice - St Johns Hospice Severn Hospice Community Of also interesting note do not rinse your mouth afterwards to allow fluoride to act
Non foaming toothpaste
Sodium laureth sulfate (SLS) or sodium lauryl ether sulfate (SLES) is a detergent and surfactant found in many personal care products (soaps shampoos toothpastes etc) bull It makes the toothpaste froth
bull SLS Free toothpastes are available
bull Make sure they are fluoride based
bull Less drying than normal toothpaste
bull Take a while to get used to
31
Denture Care
bull A huge area and confusing
bull A lot of different products and makes
bull Dependent upon what the denture is made of ie type of plastic and if contains metal or ceramic or not
bull All do come with their own recommendations
bull Recommend taking dentures out and soaking overnight withhellip
bull Chlorhexadine 02 MW is safe with all (however risks staining the teeth pink) bull Steradent is also very safe as a cleaning agent
bull Toothpaste (with or without fluoride) is corroding and dentures should not be
brushed with this rather use soap and water and rinse well
bull If remaining teeth they should be brushed as normal with fluoride toothpaste
bull Dentures should be taken out at night unless strong patient preference to leave in
32
Painful mouth
I collated a local guideline on the evidence available from the sources mentioned earlier and then expert opinion from my colleagues as to the order and preferences
bull Is it mucositis (Recent chemo or radiotherapy)
bull Recommendations of a baby (soft) toothbrushes to examine a mouth and clean a mucky mouth
bull Some evidence for Benzydamine Hydrochloride 015 oral rinse (Difflam) 10-15ml rinsegargle for 20-30sec QDS Benzydamine Hydrochloride Oromucosal spray 015 QDS
bull Most common problem is battling onhellip If treatment stings stop and re-assess
bull Many other options
Thrush
It is very difficult on occasion to differentiate between a coated mouth and thrush A couple of possible useful differentiating factors (although none are certain) - open for discussion 1) plaques on softhard palate (anywhere but tongue) - more likely thrush 2) Isolated on tongue - less likely thrush 3) plaques easily cleaned away with soft toothbrush - less likely thrush 4) mucky plaques - less likely thrush With all considerations made and there could be duel pathology consider a trail of treatment in conjunction with good oral hygiene care
35
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had had an input
Re audited the ward on the 17th June
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
httpswwwyoutubecomwatchv=asumR-n2e6k
Oxygen Tubing
Ignition with lighter Ignition with blow torch
Petroleum jelly on
it own
Melted never ignited Melted 120 seconds to
ignite
Petroleum jelly
mixed with oxygen
10min (high flow)
Melted never ignited Melted 111 second to
ignite
Cotton wool on its
own
Ignition 3 seconds burn
time 45 seconds
Ignition instant burn time
40 seconds
Cotton wool mixed
with petroleum jelly
Ignition 11 seconds
burn time 197 seconds
Ignition instant burn time
113 seconds
Oxygen tubing Ignition 18 seconds
burn time 10 seconds
Ignition instant burn time
8 seconds
In gathering the opinions of 52 carers and nursing colleagues in
Bedford Hospital Addenbrooks and Sue Ryder Hospice in relation
to the use of petroleum Jelly with oxygen the following concerns
were highlighted
1) Risk of blame if anything untoward happens
2) Potential to be told off by seniors
3) Must not challenge policy even if I personally disagree
4) The change would not be sustained by my colleagues
A lot of resistancehellip Why
There is no evidence that Vaseline is superior to aqueous products at maintaining moisture in the mouth Howeverhellip In my expereince (and I would argue the vast majority of carers and nurses) would use vaseline for themselves and think its superior to aquos products What do you think
28
Brushing teeth
1 Hale KJ American Academy of Pediatrics Section on Pediatric
Dentistry Oral health risk assessment timing and establishment
of the dental home Pediatrics 2003 1111113
2 Beltraacuten-Aguilar ED Barker LK Canto MT et al Surveillance for
dental caries dental sealants tooth retention edentulism and
enamel fluorosis--United States 1988-1994 and 1999-2002
MMWR Surveill Summ 2005 541
3 NIDR the prevalence of dental caries in United States children
The National Caries Prevalence Survey 1979-1989 NIH
Publication 82-2245 National Instutute of Dental Research
National Caries Program 1981
4 Brunelle JA Oral health of United States children The National
Survey of Dental Caries in US School Children 1986-1987 NIH
Publication 9-2247 National Institute of Dental Research
Epidemiology and Disease Prevention Program 1989
5 Kelly JE Harvey CR Basic data on dental examination findings
of persons 1-74 years United States 1971-1974 Vital Health
Stat 11 1979 1
There is clear consensus throughout dental literature regarding the importance of regular brushing with a fluoride toothpaste - generally recommending after every meal
Are we brushing teeth NI Hospice I was assured we were brushing teeth at least twice day So I measured ithellip A single night 7 out of the 13 patients got their teeth brushed twicendash NI hospice St Johns Hospice Sue Ryder That would never happen to us we definitely do it twice day So I measured ithellip 13 out of 20 patients got their teeth brushed twice - St Johns Hospice Severn Hospice Community Of also interesting note do not rinse your mouth afterwards to allow fluoride to act
Non foaming toothpaste
Sodium laureth sulfate (SLS) or sodium lauryl ether sulfate (SLES) is a detergent and surfactant found in many personal care products (soaps shampoos toothpastes etc) bull It makes the toothpaste froth
bull SLS Free toothpastes are available
bull Make sure they are fluoride based
bull Less drying than normal toothpaste
bull Take a while to get used to
31
Denture Care
bull A huge area and confusing
bull A lot of different products and makes
bull Dependent upon what the denture is made of ie type of plastic and if contains metal or ceramic or not
bull All do come with their own recommendations
bull Recommend taking dentures out and soaking overnight withhellip
bull Chlorhexadine 02 MW is safe with all (however risks staining the teeth pink) bull Steradent is also very safe as a cleaning agent
bull Toothpaste (with or without fluoride) is corroding and dentures should not be
brushed with this rather use soap and water and rinse well
bull If remaining teeth they should be brushed as normal with fluoride toothpaste
bull Dentures should be taken out at night unless strong patient preference to leave in
32
Painful mouth
I collated a local guideline on the evidence available from the sources mentioned earlier and then expert opinion from my colleagues as to the order and preferences
bull Is it mucositis (Recent chemo or radiotherapy)
bull Recommendations of a baby (soft) toothbrushes to examine a mouth and clean a mucky mouth
bull Some evidence for Benzydamine Hydrochloride 015 oral rinse (Difflam) 10-15ml rinsegargle for 20-30sec QDS Benzydamine Hydrochloride Oromucosal spray 015 QDS
bull Most common problem is battling onhellip If treatment stings stop and re-assess
bull Many other options
Thrush
It is very difficult on occasion to differentiate between a coated mouth and thrush A couple of possible useful differentiating factors (although none are certain) - open for discussion 1) plaques on softhard palate (anywhere but tongue) - more likely thrush 2) Isolated on tongue - less likely thrush 3) plaques easily cleaned away with soft toothbrush - less likely thrush 4) mucky plaques - less likely thrush With all considerations made and there could be duel pathology consider a trail of treatment in conjunction with good oral hygiene care
35
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had had an input
Re audited the ward on the 17th June
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
Ignition with lighter Ignition with blow torch
Petroleum jelly on
it own
Melted never ignited Melted 120 seconds to
ignite
Petroleum jelly
mixed with oxygen
10min (high flow)
Melted never ignited Melted 111 second to
ignite
Cotton wool on its
own
Ignition 3 seconds burn
time 45 seconds
Ignition instant burn time
40 seconds
Cotton wool mixed
with petroleum jelly
Ignition 11 seconds
burn time 197 seconds
Ignition instant burn time
113 seconds
Oxygen tubing Ignition 18 seconds
burn time 10 seconds
Ignition instant burn time
8 seconds
In gathering the opinions of 52 carers and nursing colleagues in
Bedford Hospital Addenbrooks and Sue Ryder Hospice in relation
to the use of petroleum Jelly with oxygen the following concerns
were highlighted
1) Risk of blame if anything untoward happens
2) Potential to be told off by seniors
3) Must not challenge policy even if I personally disagree
4) The change would not be sustained by my colleagues
A lot of resistancehellip Why
There is no evidence that Vaseline is superior to aqueous products at maintaining moisture in the mouth Howeverhellip In my expereince (and I would argue the vast majority of carers and nurses) would use vaseline for themselves and think its superior to aquos products What do you think
28
Brushing teeth
1 Hale KJ American Academy of Pediatrics Section on Pediatric
Dentistry Oral health risk assessment timing and establishment
of the dental home Pediatrics 2003 1111113
2 Beltraacuten-Aguilar ED Barker LK Canto MT et al Surveillance for
dental caries dental sealants tooth retention edentulism and
enamel fluorosis--United States 1988-1994 and 1999-2002
MMWR Surveill Summ 2005 541
3 NIDR the prevalence of dental caries in United States children
The National Caries Prevalence Survey 1979-1989 NIH
Publication 82-2245 National Instutute of Dental Research
National Caries Program 1981
4 Brunelle JA Oral health of United States children The National
Survey of Dental Caries in US School Children 1986-1987 NIH
Publication 9-2247 National Institute of Dental Research
Epidemiology and Disease Prevention Program 1989
5 Kelly JE Harvey CR Basic data on dental examination findings
of persons 1-74 years United States 1971-1974 Vital Health
Stat 11 1979 1
There is clear consensus throughout dental literature regarding the importance of regular brushing with a fluoride toothpaste - generally recommending after every meal
Are we brushing teeth NI Hospice I was assured we were brushing teeth at least twice day So I measured ithellip A single night 7 out of the 13 patients got their teeth brushed twicendash NI hospice St Johns Hospice Sue Ryder That would never happen to us we definitely do it twice day So I measured ithellip 13 out of 20 patients got their teeth brushed twice - St Johns Hospice Severn Hospice Community Of also interesting note do not rinse your mouth afterwards to allow fluoride to act
Non foaming toothpaste
Sodium laureth sulfate (SLS) or sodium lauryl ether sulfate (SLES) is a detergent and surfactant found in many personal care products (soaps shampoos toothpastes etc) bull It makes the toothpaste froth
bull SLS Free toothpastes are available
bull Make sure they are fluoride based
bull Less drying than normal toothpaste
bull Take a while to get used to
31
Denture Care
bull A huge area and confusing
bull A lot of different products and makes
bull Dependent upon what the denture is made of ie type of plastic and if contains metal or ceramic or not
bull All do come with their own recommendations
bull Recommend taking dentures out and soaking overnight withhellip
bull Chlorhexadine 02 MW is safe with all (however risks staining the teeth pink) bull Steradent is also very safe as a cleaning agent
bull Toothpaste (with or without fluoride) is corroding and dentures should not be
brushed with this rather use soap and water and rinse well
bull If remaining teeth they should be brushed as normal with fluoride toothpaste
bull Dentures should be taken out at night unless strong patient preference to leave in
32
Painful mouth
I collated a local guideline on the evidence available from the sources mentioned earlier and then expert opinion from my colleagues as to the order and preferences
bull Is it mucositis (Recent chemo or radiotherapy)
bull Recommendations of a baby (soft) toothbrushes to examine a mouth and clean a mucky mouth
bull Some evidence for Benzydamine Hydrochloride 015 oral rinse (Difflam) 10-15ml rinsegargle for 20-30sec QDS Benzydamine Hydrochloride Oromucosal spray 015 QDS
bull Most common problem is battling onhellip If treatment stings stop and re-assess
bull Many other options
Thrush
It is very difficult on occasion to differentiate between a coated mouth and thrush A couple of possible useful differentiating factors (although none are certain) - open for discussion 1) plaques on softhard palate (anywhere but tongue) - more likely thrush 2) Isolated on tongue - less likely thrush 3) plaques easily cleaned away with soft toothbrush - less likely thrush 4) mucky plaques - less likely thrush With all considerations made and there could be duel pathology consider a trail of treatment in conjunction with good oral hygiene care
35
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had had an input
Re audited the ward on the 17th June
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
In gathering the opinions of 52 carers and nursing colleagues in
Bedford Hospital Addenbrooks and Sue Ryder Hospice in relation
to the use of petroleum Jelly with oxygen the following concerns
were highlighted
1) Risk of blame if anything untoward happens
2) Potential to be told off by seniors
3) Must not challenge policy even if I personally disagree
4) The change would not be sustained by my colleagues
A lot of resistancehellip Why
There is no evidence that Vaseline is superior to aqueous products at maintaining moisture in the mouth Howeverhellip In my expereince (and I would argue the vast majority of carers and nurses) would use vaseline for themselves and think its superior to aquos products What do you think
28
Brushing teeth
1 Hale KJ American Academy of Pediatrics Section on Pediatric
Dentistry Oral health risk assessment timing and establishment
of the dental home Pediatrics 2003 1111113
2 Beltraacuten-Aguilar ED Barker LK Canto MT et al Surveillance for
dental caries dental sealants tooth retention edentulism and
enamel fluorosis--United States 1988-1994 and 1999-2002
MMWR Surveill Summ 2005 541
3 NIDR the prevalence of dental caries in United States children
The National Caries Prevalence Survey 1979-1989 NIH
Publication 82-2245 National Instutute of Dental Research
National Caries Program 1981
4 Brunelle JA Oral health of United States children The National
Survey of Dental Caries in US School Children 1986-1987 NIH
Publication 9-2247 National Institute of Dental Research
Epidemiology and Disease Prevention Program 1989
5 Kelly JE Harvey CR Basic data on dental examination findings
of persons 1-74 years United States 1971-1974 Vital Health
Stat 11 1979 1
There is clear consensus throughout dental literature regarding the importance of regular brushing with a fluoride toothpaste - generally recommending after every meal
Are we brushing teeth NI Hospice I was assured we were brushing teeth at least twice day So I measured ithellip A single night 7 out of the 13 patients got their teeth brushed twicendash NI hospice St Johns Hospice Sue Ryder That would never happen to us we definitely do it twice day So I measured ithellip 13 out of 20 patients got their teeth brushed twice - St Johns Hospice Severn Hospice Community Of also interesting note do not rinse your mouth afterwards to allow fluoride to act
Non foaming toothpaste
Sodium laureth sulfate (SLS) or sodium lauryl ether sulfate (SLES) is a detergent and surfactant found in many personal care products (soaps shampoos toothpastes etc) bull It makes the toothpaste froth
bull SLS Free toothpastes are available
bull Make sure they are fluoride based
bull Less drying than normal toothpaste
bull Take a while to get used to
31
Denture Care
bull A huge area and confusing
bull A lot of different products and makes
bull Dependent upon what the denture is made of ie type of plastic and if contains metal or ceramic or not
bull All do come with their own recommendations
bull Recommend taking dentures out and soaking overnight withhellip
bull Chlorhexadine 02 MW is safe with all (however risks staining the teeth pink) bull Steradent is also very safe as a cleaning agent
bull Toothpaste (with or without fluoride) is corroding and dentures should not be
brushed with this rather use soap and water and rinse well
bull If remaining teeth they should be brushed as normal with fluoride toothpaste
bull Dentures should be taken out at night unless strong patient preference to leave in
32
Painful mouth
I collated a local guideline on the evidence available from the sources mentioned earlier and then expert opinion from my colleagues as to the order and preferences
bull Is it mucositis (Recent chemo or radiotherapy)
bull Recommendations of a baby (soft) toothbrushes to examine a mouth and clean a mucky mouth
bull Some evidence for Benzydamine Hydrochloride 015 oral rinse (Difflam) 10-15ml rinsegargle for 20-30sec QDS Benzydamine Hydrochloride Oromucosal spray 015 QDS
bull Most common problem is battling onhellip If treatment stings stop and re-assess
bull Many other options
Thrush
It is very difficult on occasion to differentiate between a coated mouth and thrush A couple of possible useful differentiating factors (although none are certain) - open for discussion 1) plaques on softhard palate (anywhere but tongue) - more likely thrush 2) Isolated on tongue - less likely thrush 3) plaques easily cleaned away with soft toothbrush - less likely thrush 4) mucky plaques - less likely thrush With all considerations made and there could be duel pathology consider a trail of treatment in conjunction with good oral hygiene care
35
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had had an input
Re audited the ward on the 17th June
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
There is no evidence that Vaseline is superior to aqueous products at maintaining moisture in the mouth Howeverhellip In my expereince (and I would argue the vast majority of carers and nurses) would use vaseline for themselves and think its superior to aquos products What do you think
28
Brushing teeth
1 Hale KJ American Academy of Pediatrics Section on Pediatric
Dentistry Oral health risk assessment timing and establishment
of the dental home Pediatrics 2003 1111113
2 Beltraacuten-Aguilar ED Barker LK Canto MT et al Surveillance for
dental caries dental sealants tooth retention edentulism and
enamel fluorosis--United States 1988-1994 and 1999-2002
MMWR Surveill Summ 2005 541
3 NIDR the prevalence of dental caries in United States children
The National Caries Prevalence Survey 1979-1989 NIH
Publication 82-2245 National Instutute of Dental Research
National Caries Program 1981
4 Brunelle JA Oral health of United States children The National
Survey of Dental Caries in US School Children 1986-1987 NIH
Publication 9-2247 National Institute of Dental Research
Epidemiology and Disease Prevention Program 1989
5 Kelly JE Harvey CR Basic data on dental examination findings
of persons 1-74 years United States 1971-1974 Vital Health
Stat 11 1979 1
There is clear consensus throughout dental literature regarding the importance of regular brushing with a fluoride toothpaste - generally recommending after every meal
Are we brushing teeth NI Hospice I was assured we were brushing teeth at least twice day So I measured ithellip A single night 7 out of the 13 patients got their teeth brushed twicendash NI hospice St Johns Hospice Sue Ryder That would never happen to us we definitely do it twice day So I measured ithellip 13 out of 20 patients got their teeth brushed twice - St Johns Hospice Severn Hospice Community Of also interesting note do not rinse your mouth afterwards to allow fluoride to act
Non foaming toothpaste
Sodium laureth sulfate (SLS) or sodium lauryl ether sulfate (SLES) is a detergent and surfactant found in many personal care products (soaps shampoos toothpastes etc) bull It makes the toothpaste froth
bull SLS Free toothpastes are available
bull Make sure they are fluoride based
bull Less drying than normal toothpaste
bull Take a while to get used to
31
Denture Care
bull A huge area and confusing
bull A lot of different products and makes
bull Dependent upon what the denture is made of ie type of plastic and if contains metal or ceramic or not
bull All do come with their own recommendations
bull Recommend taking dentures out and soaking overnight withhellip
bull Chlorhexadine 02 MW is safe with all (however risks staining the teeth pink) bull Steradent is also very safe as a cleaning agent
bull Toothpaste (with or without fluoride) is corroding and dentures should not be
brushed with this rather use soap and water and rinse well
bull If remaining teeth they should be brushed as normal with fluoride toothpaste
bull Dentures should be taken out at night unless strong patient preference to leave in
32
Painful mouth
I collated a local guideline on the evidence available from the sources mentioned earlier and then expert opinion from my colleagues as to the order and preferences
bull Is it mucositis (Recent chemo or radiotherapy)
bull Recommendations of a baby (soft) toothbrushes to examine a mouth and clean a mucky mouth
bull Some evidence for Benzydamine Hydrochloride 015 oral rinse (Difflam) 10-15ml rinsegargle for 20-30sec QDS Benzydamine Hydrochloride Oromucosal spray 015 QDS
bull Most common problem is battling onhellip If treatment stings stop and re-assess
bull Many other options
Thrush
It is very difficult on occasion to differentiate between a coated mouth and thrush A couple of possible useful differentiating factors (although none are certain) - open for discussion 1) plaques on softhard palate (anywhere but tongue) - more likely thrush 2) Isolated on tongue - less likely thrush 3) plaques easily cleaned away with soft toothbrush - less likely thrush 4) mucky plaques - less likely thrush With all considerations made and there could be duel pathology consider a trail of treatment in conjunction with good oral hygiene care
35
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had had an input
Re audited the ward on the 17th June
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
28
Brushing teeth
1 Hale KJ American Academy of Pediatrics Section on Pediatric
Dentistry Oral health risk assessment timing and establishment
of the dental home Pediatrics 2003 1111113
2 Beltraacuten-Aguilar ED Barker LK Canto MT et al Surveillance for
dental caries dental sealants tooth retention edentulism and
enamel fluorosis--United States 1988-1994 and 1999-2002
MMWR Surveill Summ 2005 541
3 NIDR the prevalence of dental caries in United States children
The National Caries Prevalence Survey 1979-1989 NIH
Publication 82-2245 National Instutute of Dental Research
National Caries Program 1981
4 Brunelle JA Oral health of United States children The National
Survey of Dental Caries in US School Children 1986-1987 NIH
Publication 9-2247 National Institute of Dental Research
Epidemiology and Disease Prevention Program 1989
5 Kelly JE Harvey CR Basic data on dental examination findings
of persons 1-74 years United States 1971-1974 Vital Health
Stat 11 1979 1
There is clear consensus throughout dental literature regarding the importance of regular brushing with a fluoride toothpaste - generally recommending after every meal
Are we brushing teeth NI Hospice I was assured we were brushing teeth at least twice day So I measured ithellip A single night 7 out of the 13 patients got their teeth brushed twicendash NI hospice St Johns Hospice Sue Ryder That would never happen to us we definitely do it twice day So I measured ithellip 13 out of 20 patients got their teeth brushed twice - St Johns Hospice Severn Hospice Community Of also interesting note do not rinse your mouth afterwards to allow fluoride to act
Non foaming toothpaste
Sodium laureth sulfate (SLS) or sodium lauryl ether sulfate (SLES) is a detergent and surfactant found in many personal care products (soaps shampoos toothpastes etc) bull It makes the toothpaste froth
bull SLS Free toothpastes are available
bull Make sure they are fluoride based
bull Less drying than normal toothpaste
bull Take a while to get used to
31
Denture Care
bull A huge area and confusing
bull A lot of different products and makes
bull Dependent upon what the denture is made of ie type of plastic and if contains metal or ceramic or not
bull All do come with their own recommendations
bull Recommend taking dentures out and soaking overnight withhellip
bull Chlorhexadine 02 MW is safe with all (however risks staining the teeth pink) bull Steradent is also very safe as a cleaning agent
bull Toothpaste (with or without fluoride) is corroding and dentures should not be
brushed with this rather use soap and water and rinse well
bull If remaining teeth they should be brushed as normal with fluoride toothpaste
bull Dentures should be taken out at night unless strong patient preference to leave in
32
Painful mouth
I collated a local guideline on the evidence available from the sources mentioned earlier and then expert opinion from my colleagues as to the order and preferences
bull Is it mucositis (Recent chemo or radiotherapy)
bull Recommendations of a baby (soft) toothbrushes to examine a mouth and clean a mucky mouth
bull Some evidence for Benzydamine Hydrochloride 015 oral rinse (Difflam) 10-15ml rinsegargle for 20-30sec QDS Benzydamine Hydrochloride Oromucosal spray 015 QDS
bull Most common problem is battling onhellip If treatment stings stop and re-assess
bull Many other options
Thrush
It is very difficult on occasion to differentiate between a coated mouth and thrush A couple of possible useful differentiating factors (although none are certain) - open for discussion 1) plaques on softhard palate (anywhere but tongue) - more likely thrush 2) Isolated on tongue - less likely thrush 3) plaques easily cleaned away with soft toothbrush - less likely thrush 4) mucky plaques - less likely thrush With all considerations made and there could be duel pathology consider a trail of treatment in conjunction with good oral hygiene care
35
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had had an input
Re audited the ward on the 17th June
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
Are we brushing teeth NI Hospice I was assured we were brushing teeth at least twice day So I measured ithellip A single night 7 out of the 13 patients got their teeth brushed twicendash NI hospice St Johns Hospice Sue Ryder That would never happen to us we definitely do it twice day So I measured ithellip 13 out of 20 patients got their teeth brushed twice - St Johns Hospice Severn Hospice Community Of also interesting note do not rinse your mouth afterwards to allow fluoride to act
Non foaming toothpaste
Sodium laureth sulfate (SLS) or sodium lauryl ether sulfate (SLES) is a detergent and surfactant found in many personal care products (soaps shampoos toothpastes etc) bull It makes the toothpaste froth
bull SLS Free toothpastes are available
bull Make sure they are fluoride based
bull Less drying than normal toothpaste
bull Take a while to get used to
31
Denture Care
bull A huge area and confusing
bull A lot of different products and makes
bull Dependent upon what the denture is made of ie type of plastic and if contains metal or ceramic or not
bull All do come with their own recommendations
bull Recommend taking dentures out and soaking overnight withhellip
bull Chlorhexadine 02 MW is safe with all (however risks staining the teeth pink) bull Steradent is also very safe as a cleaning agent
bull Toothpaste (with or without fluoride) is corroding and dentures should not be
brushed with this rather use soap and water and rinse well
bull If remaining teeth they should be brushed as normal with fluoride toothpaste
bull Dentures should be taken out at night unless strong patient preference to leave in
32
Painful mouth
I collated a local guideline on the evidence available from the sources mentioned earlier and then expert opinion from my colleagues as to the order and preferences
bull Is it mucositis (Recent chemo or radiotherapy)
bull Recommendations of a baby (soft) toothbrushes to examine a mouth and clean a mucky mouth
bull Some evidence for Benzydamine Hydrochloride 015 oral rinse (Difflam) 10-15ml rinsegargle for 20-30sec QDS Benzydamine Hydrochloride Oromucosal spray 015 QDS
bull Most common problem is battling onhellip If treatment stings stop and re-assess
bull Many other options
Thrush
It is very difficult on occasion to differentiate between a coated mouth and thrush A couple of possible useful differentiating factors (although none are certain) - open for discussion 1) plaques on softhard palate (anywhere but tongue) - more likely thrush 2) Isolated on tongue - less likely thrush 3) plaques easily cleaned away with soft toothbrush - less likely thrush 4) mucky plaques - less likely thrush With all considerations made and there could be duel pathology consider a trail of treatment in conjunction with good oral hygiene care
35
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had had an input
Re audited the ward on the 17th June
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
Non foaming toothpaste
Sodium laureth sulfate (SLS) or sodium lauryl ether sulfate (SLES) is a detergent and surfactant found in many personal care products (soaps shampoos toothpastes etc) bull It makes the toothpaste froth
bull SLS Free toothpastes are available
bull Make sure they are fluoride based
bull Less drying than normal toothpaste
bull Take a while to get used to
31
Denture Care
bull A huge area and confusing
bull A lot of different products and makes
bull Dependent upon what the denture is made of ie type of plastic and if contains metal or ceramic or not
bull All do come with their own recommendations
bull Recommend taking dentures out and soaking overnight withhellip
bull Chlorhexadine 02 MW is safe with all (however risks staining the teeth pink) bull Steradent is also very safe as a cleaning agent
bull Toothpaste (with or without fluoride) is corroding and dentures should not be
brushed with this rather use soap and water and rinse well
bull If remaining teeth they should be brushed as normal with fluoride toothpaste
bull Dentures should be taken out at night unless strong patient preference to leave in
32
Painful mouth
I collated a local guideline on the evidence available from the sources mentioned earlier and then expert opinion from my colleagues as to the order and preferences
bull Is it mucositis (Recent chemo or radiotherapy)
bull Recommendations of a baby (soft) toothbrushes to examine a mouth and clean a mucky mouth
bull Some evidence for Benzydamine Hydrochloride 015 oral rinse (Difflam) 10-15ml rinsegargle for 20-30sec QDS Benzydamine Hydrochloride Oromucosal spray 015 QDS
bull Most common problem is battling onhellip If treatment stings stop and re-assess
bull Many other options
Thrush
It is very difficult on occasion to differentiate between a coated mouth and thrush A couple of possible useful differentiating factors (although none are certain) - open for discussion 1) plaques on softhard palate (anywhere but tongue) - more likely thrush 2) Isolated on tongue - less likely thrush 3) plaques easily cleaned away with soft toothbrush - less likely thrush 4) mucky plaques - less likely thrush With all considerations made and there could be duel pathology consider a trail of treatment in conjunction with good oral hygiene care
35
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had had an input
Re audited the ward on the 17th June
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
31
Denture Care
bull A huge area and confusing
bull A lot of different products and makes
bull Dependent upon what the denture is made of ie type of plastic and if contains metal or ceramic or not
bull All do come with their own recommendations
bull Recommend taking dentures out and soaking overnight withhellip
bull Chlorhexadine 02 MW is safe with all (however risks staining the teeth pink) bull Steradent is also very safe as a cleaning agent
bull Toothpaste (with or without fluoride) is corroding and dentures should not be
brushed with this rather use soap and water and rinse well
bull If remaining teeth they should be brushed as normal with fluoride toothpaste
bull Dentures should be taken out at night unless strong patient preference to leave in
32
Painful mouth
I collated a local guideline on the evidence available from the sources mentioned earlier and then expert opinion from my colleagues as to the order and preferences
bull Is it mucositis (Recent chemo or radiotherapy)
bull Recommendations of a baby (soft) toothbrushes to examine a mouth and clean a mucky mouth
bull Some evidence for Benzydamine Hydrochloride 015 oral rinse (Difflam) 10-15ml rinsegargle for 20-30sec QDS Benzydamine Hydrochloride Oromucosal spray 015 QDS
bull Most common problem is battling onhellip If treatment stings stop and re-assess
bull Many other options
Thrush
It is very difficult on occasion to differentiate between a coated mouth and thrush A couple of possible useful differentiating factors (although none are certain) - open for discussion 1) plaques on softhard palate (anywhere but tongue) - more likely thrush 2) Isolated on tongue - less likely thrush 3) plaques easily cleaned away with soft toothbrush - less likely thrush 4) mucky plaques - less likely thrush With all considerations made and there could be duel pathology consider a trail of treatment in conjunction with good oral hygiene care
35
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had had an input
Re audited the ward on the 17th June
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
32
Painful mouth
I collated a local guideline on the evidence available from the sources mentioned earlier and then expert opinion from my colleagues as to the order and preferences
bull Is it mucositis (Recent chemo or radiotherapy)
bull Recommendations of a baby (soft) toothbrushes to examine a mouth and clean a mucky mouth
bull Some evidence for Benzydamine Hydrochloride 015 oral rinse (Difflam) 10-15ml rinsegargle for 20-30sec QDS Benzydamine Hydrochloride Oromucosal spray 015 QDS
bull Most common problem is battling onhellip If treatment stings stop and re-assess
bull Many other options
Thrush
It is very difficult on occasion to differentiate between a coated mouth and thrush A couple of possible useful differentiating factors (although none are certain) - open for discussion 1) plaques on softhard palate (anywhere but tongue) - more likely thrush 2) Isolated on tongue - less likely thrush 3) plaques easily cleaned away with soft toothbrush - less likely thrush 4) mucky plaques - less likely thrush With all considerations made and there could be duel pathology consider a trail of treatment in conjunction with good oral hygiene care
35
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had had an input
Re audited the ward on the 17th June
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
Thrush
It is very difficult on occasion to differentiate between a coated mouth and thrush A couple of possible useful differentiating factors (although none are certain) - open for discussion 1) plaques on softhard palate (anywhere but tongue) - more likely thrush 2) Isolated on tongue - less likely thrush 3) plaques easily cleaned away with soft toothbrush - less likely thrush 4) mucky plaques - less likely thrush With all considerations made and there could be duel pathology consider a trail of treatment in conjunction with good oral hygiene care
35
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had had an input
Re audited the ward on the 17th June
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
35
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had had an input
Re audited the ward on the 17th June
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
36
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
0
3
5
8
10
13
MO JM EMC EMc WW JS JK AM MW RS JSM BS
overall dryness score
overall dryness score
patient
overall dryness score
MO 5
JM 5
EMC 5
EMc 5
WW 6
JS 6
JK 7
AM 7
MW 8
RS 10
JSM 10
BS 10
Mean 69 72
17715
0 ndash not dry 10 ndash as dry as can be
Removed 3 patients ndash 2 could not respond 1 confused
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
38
Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
39
Pre Post
0 5
4 5
4 5
5 5
5 6
5 6
6 7
6 7
8 8
8 10
9 10
9 10
10
0
3
5
8
10
13
Pre Post
The Mean went up from 62 pre to 72 post People thought their mouth was drier after the poster was up for a week
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
40
Pre Post
mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
41
41
18
mild 0-3 Moderate 3-7 Severe 8-10
47
33
20
mild 0-3 Moderate 3-7 Severe 8-10
My rating on how dry their mouths seemed
Pre Post
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
41
Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
0 175 35 525 7 875
mild 0-3
Moderate 3-7
Severe 8-10
Pre My assesment Pre Patients subjective opinion
0 2 4 6 8 10
mild 0-3
Moderate 3-7
Severe 8-10
Post My Assessment Post Patients subjective opinion
Patients are subjectively experiencing a dryer mouth than I was seeing
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
42
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
Conclusion
bull I believe this is the most up to date and evidence based approach to mouthcare
bull It has been implemented in Northern Ireland Bedford Hospital and 3 hospices
bull It is a quality improvement project therefore is flexible I would love your feedback and suggestions
bull Mouthcare is not just a nursing or carer thing it is all the MDT responsibility
bull A good access point to help relatives care for their loved ones and built a trusting rapor with staff
bull Would a leaflet help
bull Is part of (and demonstrates well) patient focused care
bull Donrsquot underestimate the symptom burden of your mouth
51
any questions
51
any questions
