1. CCA Study Notes: Oral Hygiene and Client-Centred Mouth Care

The Big Picture

Mouth care keeps the mouth and teeth clean. It also helps prevent odours, infections, cavities, and gum disease. Good mouth care improves comfort and helps food taste better.

Some clients complete their own mouth care. Others need equipment set up, reminders, partial help, or full assistance. The care plan and your supervisor guide the type of help each client needs.

Safe mouth care also means respecting the client’s choices, privacy, dignity, and independence while watching for problems that need prompt reporting.

Look for Nova Scotia CCA Notes throughout this page for current provincial guidance.

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Course Notes: Key Ideas You Need to Know

What Oral Hygiene Does

Oral hygiene, also called mouth care, keeps the mouth and teeth clean.

Good oral hygiene:

• Prevents mouth odours
• Helps prevent infections
• Helps prevent cavities, also called dental caries
• Increases comfort
• Helps food taste better
• Helps prevent periodontal disease

Periodontal disease is inflammation of the tissues around the teeth. It is also called gum disease or pyorrhea.

Oral care forms an important part of overall physical health.

Biofilm, Tartar, and Periodontal Disease

Poor oral hygiene allows biofilm to build up.

Biofilm is a thin film that sticks to the teeth. It contains saliva, microbes, and other substances. Biofilm contributes to tooth decay and cavities.

When biofilm hardens, it becomes tartar.

Tartar collects near the gum line around the neck of the tooth. This buildup contributes to periodontal disease.

As periodontal disease develops:

• Gums become red
• Gums become swollen
• Gums bleed easily
• Bone becomes damaged as the disease progresses
• Teeth loosen
• Tooth loss eventually occurs

Key fact: Bleeding gums during mouth care usually show inflammation. Bleeding gums mean the client needs more mouth care, not less.

Changes That Affect the Mouth

Illness and disease often cause a bad taste in the mouth.

Some medications and diseases cause:

• A whitish coating on the mouth and tongue
• Redness of the mouth and tongue
• Swelling of the mouth and tongue

Dry mouth has several supported causes:

• Oxygen administration
• Smoking
• Low fluid intake
• Mouth breathing
• Anxiety
• Some medications

Some medications cause enough mouth dryness to make swallowing difficult.

Oral Health and Other Health Problems

Bacteria growing in the oral cavity can enter the lungs through aspiration and contribute to respiratory diseases such as pneumonia.

Periodontal disease can increase a person’s risk of heart disease. Some studies found a greater risk of thickening of the carotid arteries in clients with oral disease. This thickening leads to heart disease.

When Clients Receive Mouth Care

The supervisor and care plan tell you what type of mouth care and assistance the client needs.

Oral hygiene is given:

• On awakening
• After each meal
• At bedtime

Some clients also complete mouth care before meals. This promotes salivation ⓘ and improves the taste of food.

Standard Practices and Gloves

During mouth care, you come into contact with the client’s mucous membranes. The mouth contains many microbes.

Safety: Wear gloves and follow Standard Practices during oral hygiene.

Basic Mouth-Care Equipment

Common oral-hygiene equipment includes:

• A soft-bristled toothbrush
• Fluoride toothpaste
• Dental floss
• Mouthwash

Replace toothbrushes every 3 months.

Clients with dentures need:

• Denture cleaner
• Denture cup
• Denture brush or toothbrush

Use only products recommended for denture cleaning. Other products can damage dentures.

Sponge Swabs and Lip Care

Sponge swabs are used for clients with sore or tender mouths and for unconscious clients.

Safety: Always check that the foam pad fits tightly on the stick. A loose foam pad presents a choking risk.

Lip moisturizers often help relieve dry lips.

What the CCA Should Observe and Report

Observe the client’s mouth, teeth, gums, tongue, lips, and dentures during mouth care.

Report these findings promptly:

• Dry, cracked, swollen, or blistered lips
• Bleeding, swollen, or red gums
• Sores or white patches on the oral mucosa or tongue
• Food or foreign objects on the tongue or in the mouth
• Missing or loose teeth
• Rough, sharp, or chipped areas on dentures
• Foul breath
• Difficulty swallowing
• Difficulty speaking
• Pain or discomfort

Safety: Missing or loose teeth present a swallowing hazard.

Report and document: Report and record your actions and observations according to employer policy. Actions, observations, and basic assessments are recorded and reported for legal reasons and to keep the rest of the health care team informed.

Supporting Independence With Mouth Care

Many clients complete their own oral hygiene. Others need help collecting or setting up equipment.

In long-term care, many clients do not complete mouth care adequately without help.

Encourage each client to remain as independent as possible according to:

• The client’s abilities
• The care plan

In community care, a client might choose to brush at the bathroom sink, kitchen sink, or bedside.

Some clients need the CCA to brush their teeth because they are weak, confused, or unable to use or move their arms.

Clients living with dementia might find mouth care difficult. Even a small amount of mouth care is better than no mouth care.

Brushing Technique

Dentists do not agree on one brushing motion. Recommendations include:

• Circular motions
• Up-and-down motions
• Side-to-side motions

They agree on one important point.

First: Start brushing at the gum line.

Flossing

Flossing is a preventive measure.

Flossing removes:

• Plaque
• Tartar
• Food lodged between teeth

Plaque and tartar cause serious gum disease that leads to loosening and loss of teeth.

Floss at least daily.

Flossing might take place:

• Before meals
• After meals
• At bedtime
• At another suitable time

You might need to floss for a client who cannot floss independently.

Follow the care plan when flossing for a client.

Children and Tooth Brushing

Parents of children up to 3 years of age should consult a health care provider to determine whether the child is at risk of tooth decay.

Children should not swallow toothpaste containing fluoride.

Give children only a small amount of fluoride toothpaste because they might swallow it.

For children aged 3 to 6 years, use no more than a green-pea-sized amount of fluoridated toothpaste at each brushing.

Children start learning to brush around 3 years of age. They might still need help because their brushing might not be thorough.

Older children often brush thoroughly but still need reminders.

Children and Flossing

Preschoolers and older children need flossing.

• Floss for preschoolers.
• Older children perform their own flossing.
• Older children still need reminders and some supervision.

Older Clients and Flossing

Some older clients never developed a flossing routine because flossing was less common in the past.

A client might refuse to floss or refuse your help with flossing.

Client choice: Respect the client’s wishes.

Report: Inform your supervisor so the care plan can be changed as needed.

Mouth Care for an Unconscious Client

Some agencies allow support workers to provide personal care to unconscious clients.

Role limit: Follow agency policy and your scope of practice if you are uncertain about the care you are allowed to provide.

Unconscious clients need special mouth care because they:

• Cannot eat or drink
• Might breathe with their mouths open
• Might receive oxygen therapy

These conditions contribute to mouth dryness and crusting on the tongue and mucous membranes.

Oral hygiene keeps the mouth clean and moist and helps prevent infection.

Cleaning Products for an Unconscious Client

The care plan tells you which cleaning agent to use.

Use sponge swabs to apply the cleaning agent.

After cleaning, apply the lip lubricant identified in the care plan to help prevent cracked lips.

Preventing Aspiration

Unconscious clients usually cannot swallow. They need protection from choking and aspiration, which means inhaling fluid or an object into the lungs.

Aspiration increases the risk of pneumonia and death.

To reduce aspiration risk:

• Position the client on one side.
• Turn the client’s head well to the side.
• Use only a small amount of fluid during mouth cleaning.

This position lets excess fluid run out of the mouth.

Sometimes oral suctioning is needed.

Keeping the Mouth Open Safely

Use a padded tongue blade to keep the unconscious client’s mouth open.

If one is not available, a padded tongue blade can be made.

Avoid: Never use your fingers to hold the client’s mouth open. The client might bite down.

A bite that breaks your skin creates a portal of entry ⓘ for microbes and can become infected.

Communication With an Unconscious Client

An unconscious client cannot answer you, but some unconscious clients hear what happens around them.

Always assume the client hears you.

• Speak respectfully before each step.
• Explain each action before you perform it.
• Tell the client when care is finished.
• Tell the client before you leave the room.

How Often Unconscious Clients Need Mouth Care

Check the care plan and ask your supervisor about the required frequency and products.

Oral hygiene for an unconscious client usually occurs at least every 2 hours.

Unconscious clients also receive repositioning at least every 2 hours.

Combining mouth care, skin care, and other comfort measures increases comfort and safety.

Denture Basics

Dentures are artificial teeth.

A client might have:

• A complete set
• A partial set

Give mouth care and clean dentures as often as natural teeth.

Handle dentures carefully. Wet dentures feel slippery and break or chip easily when dropped on a hard floor or sink.

Denture Cleaning Agents

Follow the manufacturer’s directions ⓘ for:

• How to use the cleaning product
• Required water temperature
• Soaking time

Do not soak dentures longer than recommended. Excess soaking can damage them.

Avoid: Do not use hot water. Very hot water causes dentures to warp.

Storing Dentures

Denture-storage recommendations vary.

Some dentists and denturists recommend storing dentures in a container covered with water. Dentures stored without water under this method can warp.

Other dentists and denturists recommend dry storage.

Some clients:

• Remove dentures at bedtime
• Wear dentures for meals only
• Remove dentures after meals
• Do not wear dentures continuously

Avoid: Do not wrap dentures in tissues or napkins. Someone might discard them by mistake.

Follow employer policy for dentures that will not be worn after cleaning.

Supporting Independence With Denture Care

Most clients clean their own dentures.

Some clients need help:

• Collecting supplies
• Getting to the bathroom

Role limit: Clean dentures only for clients who cannot clean them independently.

Clean the denture-soaking container regularly.

Agency rules for denture-cleaning tablets differ. Some agencies recommend them. Other agencies do not permit them.

Follow agency policy for denture cleaning.

Privacy and Dentures

Many clients dislike being seen without their dentures.

After cleaning dentures, return them to the client as quickly as possible.

Provide privacy when clients clean their own dentures.

Oral Hygiene During Daily Facility Care

Facilities provide routine hygiene care at set times. The amount of care, terminology, and procedures differ among facilities.

The care plan gives directions.

AM care means routine facility care provided before lunch. It sometimes takes place before breakfast. Mouth care often forms part of this routine.

Afternoon care takes place after lunch and before the evening meal. It usually includes oral hygiene along with other personal care.

HS care takes place at bedtime. HS means “hour of sleep.” It is also called evening care or PM care. Oral hygiene forms part of HS care.

DIPPS and Client-Centred Hygiene Care

Clients sometimes feel frustrated, angry, or embarrassed when they need help with personal hygiene.

Support workers promote DIPPS:

• Dignity
• Independence
• Individualized care
• Preferences
• Privacy
• Safety

Dignity

Hygiene is personal and private.

Clients might feel embarrassed when another person provides hygiene care, especially when the caregiver is of the opposite sex.

Support dignity by:

• Remaining calm and professional
• Explaining what you will do
• Talking to the client during care
• Listening to concerns and questions

Independence

Allow and encourage clients to complete as much self-care as possible.

Sometimes the client only needs help with part of the task.

Give the client enough time to do what they are able to do.

Check the care plan and ask your supervisor about the client’s abilities and limitations.

Individualized Care

Client-centred personal care fits the client’s:

• Choices
• Physical strengths and limitations
• Cognitive ⓘ strengths and limitations
• Personality
• Care plan

Client choice: Never force a client to receive personal care.

If a client does not cooperate with hygiene care, use gentle persuasive approaches such as re-approaching and redirecting.

Preferences

Clients often have personal hygiene routines and preferences.

Give clients a say in when and how hygiene care happens.

The care plan should reflect the client’s preferences and cultural practices.

Report: If the care plan conflicts with the client’s wishes, inform your supervisor.

Privacy

Perform hygiene procedures in a private area and limit unnecessary exposure.

Protect privacy by:

• Closing doors
• Closing privacy curtains
• Closing drapes
• Asking visitors or family members to leave during care

If a family member or friend wants to help, the client must consent.

Safety During Hygiene Care

Wear gloves during oral care.

Hand hygiene forms part of personal-care procedures.

Also wear gloves when you expect contact with:

• Blood
• Body fluids
• Secretions
• Excretions

Wear gloves if you have cuts or rashes on your hands.

Procedure: Brushing the Client’s Teeth

Pre-Procedure

1. Identify the client according to employer policy.
2. Explain the procedure.
3. Perform hand hygiene.
4. Collect the required supplies:
   • Toothbrush
   • Toothpaste
   • Mouthwash or the solution named in the care plan
   • Dental floss, if used
   • Lip moisturizer, if used
   • Glass of cool water
   • Straw
   • Kidney basin or small bowl
   • Face towel
   • Paper towels
   • Gloves
5. Place paper towels on the overbed table or work area and arrange the supplies within easy reach.
6. Provide privacy.
7. Raise the bed to a comfortable working height.

Procedure

8. Lower the bed rail near you if it is up. This step might not apply in community settings.
9. Help the client into a sitting or side-lying position facing you. This helps prevent aspiration.
10. Place a towel across the client’s chest.
11. Adjust the overbed table so you can reach it easily. This step might not apply in community settings.
12. Put on gloves.
13. Put toothpaste on the toothbrush.
14. Hold the toothbrush over the kidney basin or bowl and pour water over it.
15. Gently inspect the teeth, gums, and tongue. Look for sores, white patches, swollen gums, and loose teeth.
16. Gently brush the client’s teeth.
17. Gently brush the tongue if needed. Follow the care plan because tongue brushing makes some clients gag.
18. Let the client rinse with water. Hold the kidney basin or bowl below the chin. Repeat rinsing as needed.
19. Floss the client’s teeth according to the care plan.
20. Let the client use mouthwash or another specified solution. Hold the kidney basin or bowl below the chin.
21. Remove the towel.
22. Remove and discard the gloves. Perform hand hygiene.
23. Move the overbed table beside the bed. This step might not apply in community settings.

Post-Procedure

24. Provide for safety and comfort.
25. Put the call bell within reach. This step might not apply in community settings.
26. Lower the bed to its lowest position. Follow the care plan for bed rail use. This step might not apply in community settings.
27. Put on gloves. Clean the equipment and return it to the proper place.
28. Wipe the overbed table or work area with paper towels. Discard the paper towels.
29. Remove privacy measures.
30. Follow employer policy for dirty linen.
31. Perform hand hygiene.

Report and document: Record and report your actions, observations, and basic assessments according to employer policy.

Procedure: Assisting a Client to Brush at the Bedside

Pre-Procedure

1. Identify the client according to employer policy.
2. Explain the procedure.
3. Perform hand hygiene.
4. Collect the same supplies used for brushing the client’s teeth.
5. Place paper towels and supplies on a work area the client can reach easily.
6. Provide privacy.
7. Raise the bed to a comfortable working height.

Procedure

8. Lower the bed rail near you if it is up.
9. Position the client so brushing feels comfortable and safe.
10. Place a towel over the client’s chest.
11. Adjust the overbed table into a comfortable position for the client. This step might not apply in community settings.
12. Encourage independence. Let the client brush, rinse, floss, and use mouthwash or the specified solution. The client spits into the kidney basin or bowl.
13. Inspect the tongue and gums for redness, sores, swelling, and loose teeth.
14. Watch the client brush. Give gentle prompts or cues when needed so the client brushes all teeth and spits when necessary.
15. Remove the towel when the client finishes.
16. Move the overbed table beside the bed. This step might not apply in community settings.

Post-Procedure

17. Complete the same post-care sequence used after brushing:
    • Provide safety and comfort.
    • Place the call bell within reach when applicable.
    • Lower the bed and follow the care plan for bed rail use when applicable.
    • Wear gloves to clean and return equipment.
    • Clean the work surface and discard the paper towels.
    • Remove privacy measures.
    • Follow employer policy for dirty linen.
    • Perform hand hygiene.

Report and document: Record and report your actions and observations according to employer policy.

Procedure: Flossing the Client’s Teeth

Pre-Procedure

1. Identify the client according to employer policy.
2. Explain the procedure.
3. Perform hand hygiene.
4. Collect:
   • Kidney basin or small bowl
   • Glass of cool water
   • Dental floss
   • Face towel
   • Paper towels
   • Gloves
5. Place paper towels and supplies on the overbed table or work area within easy reach.
6. Provide privacy.
7. Raise the bed to a comfortable working height.

Procedure

8. Lower the bed rail near you if it is up.
9. Help the client into a sitting or side-lying position facing you.
10. Place a towel over the client’s chest.
11. Adjust the overbed table within easy reach. This step might not apply in community settings.
12. Put on gloves.
13. Break off a 45-cm (18-in.) piece of dental floss.
14. Hold the floss between the middle fingers of both hands.
15. Stretch the floss using your thumbs.
16. Start at the upper back tooth on the right side and work toward the left.
17. Inspect the tongue and gums for redness, sores, swelling, and loose teeth.
18. Move the floss gently up and down between the teeth.
19. Use a fresh section of floss after every second tooth.
20. Floss the lower teeth. Hold the floss with your index fingers. Use up-and-down motions and go under the gums as directed. Start on the right and work toward the left.
21. Let the client rinse. Hold the kidney basin or bowl below the chin. Repeat rinsing when needed.
22. Remove the towel.
23. Remove and discard the gloves. Perform hand hygiene.
24. Move the overbed table beside the bed. This step might not apply in community settings.

Post-Procedure

25. Complete the same post-care safety, bed-position, equipment-cleaning, surface-cleaning, privacy, linen, and hand-hygiene steps used after brushing.

Report and document: Record and report your actions and observations according to employer policy.

Procedure: Providing Mouth Care to an Unconscious Client

Pre-Procedure

1. Identify the client according to employer policy.
2. Explain the procedure. Assume the unconscious client hears you.
3. Perform hand hygiene.
4. Collect the supplies required by employer procedure:
   • Cleaning agent named in the care plan
   • Sponge swabs
   • Padded tongue blade
   • Glass of cool water
   • Face towel
   • Kidney basin or small bowl
   • Lip lubricant
   • Paper towels
   • Gloves
5. Place paper towels and supplies on the work area within easy reach.
6. Provide privacy.
7. Raise the bed to a comfortable working height.

Procedure

8. Lower the bed rail near you if it is up.
9. Position the client on their side facing you. Turn the head well to the side to help prevent aspiration.
10. Place a towel below the client’s chin.
11. Place the kidney basin or bowl below the chin to collect fluid.
12. Adjust the overbed table within easy reach. This step might not apply in community settings.
13. Put on gloves.
14. Before each action, explain what you are going to do.
15. Separate the upper and lower teeth gently with the padded tongue blade. Do not use force. Force can fracture the client’s jaw.
16. Inspect the tongue and gums for redness, sores, swelling, and loose teeth.
17. Clean the mouth using sponge swabs moistened with the cleaning agent:
    • Check that the sponge tip will not separate from the stick.
    • Clean the chewing and inner surfaces of the teeth.
    • Clean the outer surfaces.
    • Swab the roof of the mouth, insides of the cheeks, and lips.
    • Swab the tongue.
    • Moisten a clean swab with water and remove the cleaning solution from the mouth.
    • Put used swabs in the kidney basin or bowl.
18. Dry the client’s mouth with the towel.
19. Apply lubricant to the lips.
20. Remove the towel.
21. Remove the gloves and perform hand hygiene.

Post-Procedure

22. Tell the client you are going to reposition them.
23. Reposition the client and provide safety and comfort.
24. Place the call bell within reach. This step might not apply in community settings.
25. Lower the bed to its lowest position and follow the care plan for bed rail use. This step might not apply in community settings.
26. Clean the equipment and return it to the proper place.
27. Put on gloves and discard disposable items.
28. Wipe the work surface with paper towels and discard them.
29. Remove privacy measures.
30. Tell the client you are leaving the room.
31. Follow employer policy for dirty linen.
32. Perform hand hygiene.

Report and document: Record and report your actions and observations according to employer policy.

Procedure: Providing Denture Care

Pre-Procedure

1. Identify the client according to employer policy.
2. Explain the procedure.
3. Perform hand hygiene.
4. Collect:
   • Soft-bristled denture brush or toothbrush
   • Denture cup
   • Denture-cleaning agent
   • Glass of cool water
   • Straw
   • Mouthwash or another specified solution
   • Kidney basin or small bowl
   • Two face towels
   • Paper towels
   • Gauze squares
   • Gloves
5. Provide privacy.

Procedure

6. Lower the bed rail near you if it is up.
7. Place a towel over the client’s chest.
8. Put on gloves.
9. Ask the client to remove the dentures. Place them carefully in the kidney basin or bowl.
10. If the client cannot remove the dentures, use gauze for a secure grip:
    • Hold the upper denture with your thumb and index finger.
    • Move the upper denture slightly up and down to break the seal. Gently remove it and place it in the kidney basin or bowl.
    • Hold the lower denture with your thumb and index finger. Turn it slightly, lift it out, and place it in the kidney basin or bowl.
11. Raise the bed rail if it is used.
12. Take the kidney basin, denture cup, brush, and cleaner to the sink.
13. Line the sink with a towel and fill the sink with water. The towel cushions the denture if it falls.
14. Rinse the dentures under warm running water and return them to the denture cup.
15. Put the cleaning agent on the brush.
16. Brush the dentures:
    • Brush the outer surfaces with back-and-forth motions.
    • Hold the brush vertically for the inner surfaces and use upward strokes.
    • Brush the chewing surfaces with back-and-forth motions.
    • Check for rough, sharp, or chipped areas.
17. Rinse the dentures under running water. Use warm or cool water according to the cleaner manufacturer’s directions. Hot water causes warping.
18. Put the dentures in the denture cup.
19. Clean the kidney basin or bowl.
20. Bring the denture cup and kidney basin back to the client.
21. Lower the bed rail if it is up.
22. Position the client for oral hygiene.
23. Help the client rinse with mouthwash or the specified solution. Hold the kidney basin below the chin.
24. Ask the client to insert the dentures. If the client cannot:
    • Hold the upper denture firmly with your thumb and index finger.
    • Lift the upper lip with your other hand.
    • Insert the upper denture and gently press it into place with your index fingers.
    • Hold the lower denture securely with your thumb and index finger.
    • Pull the lower lip down slightly.
    • Insert the lower denture and gently press it into place.

Safety: A denture that does not fit properly presents a choking risk.

25. If the dentures will not be worn, store them safely according to employer policy.
26. Remove the towel.
27. Remove the gloves and perform hand hygiene.

Post-Procedure

28. Provide safety and comfort.
29. Put the call bell within reach. This step might not apply in community settings.
30. Follow the care plan for bed rail use. This step might not apply in community settings.
31. Clean the equipment and return it to the proper place.
32. Put on gloves and discard disposable items.
33. Remove privacy measures.
34. Follow employer policy for dirty linen.
35. Remove the gloves and perform hand hygiene.

Report and document: Record and report your actions and observations according to employer policy.

Common Mix-Ups

Wrong Idea	Better Idea
Bleeding gums mean mouth care should stop.	Bleeding gums usually show inflammation and mean more mouth care is needed.
The CCA should take over all mouth care.	Encourage the client to do as much as their abilities and care plan allow.
Every denture should always be stored in water.	Denture-storage recommendations vary. Follow employer policy.
An unconscious client does not need explanations.	Assume the client hears you and explain each step respectfully.