foumal of Advanced Nursmg, 1996,23,62-69

A comparison of the ability of foam swabs and

toothbrushes to remove dental plaque:
implications for nursing practice
Linda Susan Pearson (née Tipler) BSc RGN PhD PGCE(FE)
Lecturer m Nursing, Institute of Nursing Studies, University of Hull, HullHU6 7RX,
England

Accepted for publication 3 Febraary 1995

PEARSON L S (1996) Journal of Advanced Nursing 23, 62-69

A comparison of the ability of foam swabs and toothbrushes to remove dental
plaque: implications for nursmg practice
This study aimed to assess the impact which the use of a toothbrush and the use
of foam swabs had on the removal of dental plaque over a 6-day period Three
experiments were completed and duplicated using the author's mouth and one
of these experiments was completed a third time on a volunteer's mouth A
plaque scoring system which quantified the amount of plaque on teeth in areas
adjacent to penodontal tissue, and therefore capable of initiating inflammation,
was used after plaque had been disclosed Plaque at the gum/tooth margin
(gingival crevice plaque) and plaque between teeth (approximal plaque) was
measured At the end of each 6-day period, wbicb commenced with all tooth
surfaces clean, the ability of the toothbrush to remove plaque was consistently
better than that of swabs, and usually achieved complete visible plaque removal
from all sites In contrast, plaque remained m all sites which had been cleaned
using foam swabs (after using a 'swabbing' or 'scrubbing' technique) However,
it was possible to remove plaque from a number of gingival crevice sites with a
swab wben a varied 'any technique' was used on the visible disclosed plaque
The plaque in all approximal sites still remained after this technique An
experiment to measure the effect of using foam swabs on plaque wbich had
been allowed to accumulate over a 6 day period produced similar results The
results from this study suggest that the success of a toothbrush m removing
plaque is affected by user technique (total visible plaque removal was not
achievable), and that foam swabs are not able to remove plaque from some
'sheltered' areas of teeth (total visible plaque removal was not achievable) The
implications of these findings to nursing practice are discussed

TKrTunriTTr'TTnM uneconomic and ineffective use of resources for delivery

INTRODUCTION
Foam swabs (Figure 1) originated m the USA and have
heen used to clean the surfaces of oral tissues for people
requiring 'mouth care' in areas of Britain since the early
1970s Each 'mouth CEire' procedure may require the use
of a number of swahs, each of which is disposed of after
use Actual costs of using foam swahs m clinical areas
require local costing studies However, a numher of reports
have indicated that the cost is sigmficant and may he an
^^ quality mouth care pracbce (Hams 1980) Soon after
the arrival of foam swahs in Bntam nurses hegan reporting
them to he ineffective at cleaning oral surfaces or at leaving
some patients with a sense of comfort for little more than
a very short period of time (Howarth 1975)
Despite the early reports of ineffective use they are still
used as the main mechanical tool for mouth care in some
areas Pritchard & Mallet (1992) distil the physical aims of
mouth care as hemg to achieve or menntain clesm, moist

62 © 1996 Blackwell Science Ltd


Figure 1 Foam oral swabs (Johnson & Johnson, Asi^ol).
and infection-free oral tissues. These physical aims must
be set in the context of each person's care roquircmenLs.
THE MOUTH
Tho mouth is an environment which is colonized hy
micro-organisms (microbes) soon after birth. As the tissues
of the month change; and dttvelüp throughout life, the
microbes inhabiting each area and eacii niche (or role)
within the month alter in response to the environmental
conditions offered in each place (Donoghue 1987, Marsh
& Martin 1992).
Plaqne is the name given to Ehn film of microbes emhed-
ded in sticky products of micrnbial and salivary origin
which adheres to the teeth nnd tissues around the teeth.
The microbes whii:h make up plaque are mimerons and
diverse. Over 400 species of microbes have been isolated
from the hnman moutb and it has been estimated that a
millilitre of saliva can contain as many as 100 million
microhial cells (Marsh & Martin 199ZJ. hi ideal growth
conditions many microbes can grow ¡md divide every 30
minntes or so and therefore the cleanest mouth can he
considered to he a continuous culture vessel for many
microhes.
The microhes which inhabit the moutli, and more
especially the gingival tooth margin, have a direct eÖect
on the tissues. There is no other area in the body which
is nnder such constant sustained attack from the 'normal
flora'.
The two major dental prohlems of the world are dental
caries (teeth are dissolved away du(! to the action of acid
in tho mouth which is of microhial origin) and chronic
inflanmiatory periodontal disease (which can result in the
loss of healthy teeth due to the destruction of the support-
ive periodontal tissue), Many people in the western world
suffer from the infectious disease of dental caries. The dis-
ease is intimately linked with the diet of individuals,
which in turn encourages the growth of c:ertain microbes
that have the ahility to produce strong acids (e,g. lactic
acid) in thn mouth. These microbes are called caiiogenic
© 1996 Blackwel] Science Lid, foumal of Advanced Nursin<4, 23, f.2-09
Removing dental plaque
organisms and include Streptococcus mutans (Loesche &
Syed 1978).
In order to control the effect of such organisms one needs
to attack the problem from a nnmber of directions, e.g.
alter the diet of the population, improve the techniques
for removing plaque through glohal and local health edu-
cation initiatives, rednce the susceptibility of host tissue
(teoth) to attack by increasing the intake of fluoride via
water, toothpaste and supplements. There are regional
differences within the UK regarding the effectiveness of
these infection control measures and huge variations on a
glohal scale.
Periodontal disease
Chronic inflammatory periodontal disease affects nearly
all dentate individxials throughout the world and is the
leading cause of tooth loss in adult populations (Schei
ei al. 1959, Loe 196:5, Russell 1967). The relationship
between the organisms in plaque and the cause of the
development of this disease is not as clear as it is for the
development of caries and this is a focus of a lot of dental
research. However, there is ample evidence implicating
microbes in the initiation of gingivitis (the first stage of the
disease) and the progression to periodontitis (Socransky
1970, Palenstein Helderman 1981, Armitage ei al. 1982).
It is dental plaqtie which is the most difficult to remove
during tooth brushing which contributes directly to gingi-
vitis (approximal, sub- and sheltered supra-gingival
plaque) compared with dental caries which are usually
caused by smooth surface and fissure plaque,
The final stage of chronic periodontal disease is charac-
terized by the presence of plasma cells in the gingival
tissue and its exndate, the detachment of the periodontal
memhrane, the loss of soft tissue integrity and the résorp-
tion of alveolar bone. These changes result in the develop-
ment of periodontal pockets around the teeth and signs
üf this pocketing are looked for during routine dental
examinations.
Pathogenesis
Page & Schroeder (197B) studied the pathogenesis of
inflammatory periodontal disease and they detected
changes in the periodontal tissue 2-4 days affer the cess-
ation of oral hygiene measures in people who had no sign
of gingivitis at the beginning of the study. The impact of
this and other findings related to the growth of microbes
have implications for the practice of mouth care.
Plaque is the cause of dental caries and chronic inflam-
matory periodontal disease (and some other oral proh-
lems). Few people in the western world can boast of a
mouth free of dental caries. The onset and progression of
chronic inflammatory periodontal disease is pain-free and
most dentate individuals in the world suffer from it
63
L S Pearson
without knovtring Microbes grow very quickly and there-
fore require frequent and effective removal if the effect of
plaque is to be minimized
MOUTH CARE BY NURSES
Despite long-standing and repeated attempts to improve
the practice of mouth care given by nurses (DeWalt &
Hames 1969, Wiley 1969, DeWalt 1975, Howarth 1975,
1977, Harris 1980, Lewis 1984, Trenter Roth & Creason
1986, Hunt 1987, Miller & Rubmstem 1987, Watson 1989,
Pntchard & Mallet 1992, Clarke 1993) foam swabs are fre-
quently used in the practice of mouth care by nurses m
an attempt to clean the oral tissues for paüents/clients
In order to assess the ability of a mechanical tool to clean
the surfaces of teeth it is necessary to use a method which
(a) renders plaque visible, since quite substantial amounts
can accumulate on teeth or at tooth gingival margins m
the gingival crevice without it being visible, and (b) quanti-
fies the amount of plaque at specific sites before and after
the use of the tool A search of the nursmg literature
showed that few studies have been done to quantify the
amount of plaque remaining on teeth after using different
mouth care tools
A frequently quoted study is that of DeWalt (1975) m
which plaque accumulations were quantified by using the
sconng procedure of Greene & Vermillion (1960) Here the
amount of plaque on tooth surfaces was estimated after
using a disclosing solution and was recorded as the Eirea
of each tooth which was covered with plaque at each
plaque scoring procedure
More recent findings relating to the role of plaque m the
onset and progression of chronic inflammatory penodontal
disease in humans (reviewed m Tipler 1984) highlight the
importance of plaque which accumulates at the gmgival
crevice and approximally (Figure 2) Histologically recog-
nized tissue changes of 'healthy' gingival tissue have been
Teeth from above
Smooth surface
plaque
Teeth from the akte
Supre-ginglval
plaque
Sub-ging»a>
plaque
Qummugin Gingival crevice
plaque
Figure 2 Places where plaque accumulates on and between teeth
64
reported to occur after 2 to 4 days' cessation of oral hygiene
measures m some mdividuals (Page & Schroeder 1976)
whereas cliiucally apparent gmgivitis develops withm 7
to 21 days of plaque accumulation (Loe et al 1965,
Theilade et al 1966)
Toothbrush
Effective use of a suitable toothbrush remains the mainstay
m the prevention of gingivitis m the western world
although toothbrushing may be meffective at removing
some accumulations of plaque in areeis of the mouth of
some individuals (Addy et al 1992) Effectiveness of a
toothbrush to remove supra-gmgival plaque and visible
approximal plaque (Figure 2) can be demonstrated by
using a plaque-disclosing measure after any cleamng
procedure
The lack of repeated studies relating to the abilify of
foam swabs to remove dental plaque and the apparent
absence of any study which quantified the ability of foam
swabs to remove dental plaque which is specifically
associated with the onset and progression of chronic
penodontal disease generated the need for this study
THE STUDY
Before working with nursing staff to develop mouth care
practices and perhaps to discourage the use of foam swabs
as indicated by the current literature, it had (a) to be estab-
lished that foam swabs are ineffective at removing plaque
from teeth, and (b) to know which accumulations of plaque
were removable and conversely those which were
inaccessible to foam swabs
This study focused on the abilify of foam swabs and a
toothhrush to remove plaque from gingival crevice and
approximal sites of and between teeth, since the removal
of plaque from these sites is required to maintain or to
restore penodontal tissue health in dentate individuals
This plaque removal needs to occur as an integral part of
the global term 'mouth care' which might be prescribed
for a variefy of reasons for individuals
Snbjects
The subjects used m the study included the author and
one other person Three experiments were completed in
duplicate using the author's mouth and one of these
experiments was completed one further time m the other
person's mouth, l e m triplicate Each experiment took
place over a 6-day period to avoid the development of
clinically apparent gingivitis at sites where any inadequate
plaque removal was taking place In addition, this time
period was chosen to mimic a possible length of time over
which a dentate individual might be given mouth care m
a care setting, and therefore a time penod over which
© 1996 BlackweU Science Ltd, Journal of Advanced Nursing, 23, 62-69

plaque might he accumulating if not hemg effectively
removed
A penod of 1 week was allowed to elapse between
experiments in the author's mouth in order to allow any
gingival mñammation to heal and thus avoiding accumu-
lative tissue damage to occur The senes of three expen-
ments took place m a 6-week penod and were then
immediately repeated m the same order over the next 6
weeks
Protocol
Figure 3 illustrates the protocol used m each experiment
The lefthand column mdieates the day of study, the
middle column indicates the actions taken regarding
mouth care procedure, and the nghthand eolumn indicates
the points at which data collection of plaque scores took
place For personal convenience each experiment began in
the evening of day 1 and ended in the evening of day 6
One day, after usmg a toothbrush to clean all teeth, a
plaque-disclosing tablet (Boots Company Ltd, Nottingham)
was chewed until dissolved and then the solution in the
mouth was spread across each tooth surface using the
tongue and a mouth rinsing action with the lips closed
The mouth was then rinsed using tap water taking care
not to spray the stain onto clothing and skm, until the
fluid from each rinse was pale pink
Then the amount of plaque visible on the three buccal
Brush all teeth
Day1 Disclose -•• Plaque score
Remove plaque
Treat lower buccal
Days 2-6
Brush other teeth
Disclose -•• Plaque score
Day 6 Re-treat lower buecal Plaque score
Brush all teetti
Figure 3 Protocol used for experiments 1 and 2
© 1996 Blackwell Science Ltd, Joumal of Advanced Nursing, 23, 62-69
Removing dental plaque
Table 1 Plaque score descriptions
Plaque sconng system, used after disclosing plaque
0 No plaque visible
1 Less than 1 mm of plaque extending from the gingival maigin
or adjacent tooth surface
2 1 mm or more of plaque extending from the gingival maigm or
adjacent tooth surface
surfaces of eacb tootb (two approximal surfaces and one
gingival crevice surface) was scored using the plaque scor-
ing system (see Tahle 1) for each of the four teeth either
side of the mid-line in the upper and lower teeth The
plaque score at this point represented a baseline measure-
ment and a record of what might have heen scored in a
week's time in the absence of experiments occurring
Sites
The sites scored for plaque accumulation were limited to
the buccal surfaces of tbe upper and lower front eigbt teetb
for a number of reasons These surfaces are the most
accessible to score and to clean Altbough the use of a
toothbrush and a foam swab might have different ahilities
to remove plaque from other tooth surfaces, this study
focused on what might be considered tbe best performanee
areas for botb tools
Plaque scores were recorded directly onto a data collec-
tion sbeet, similar to tbat sbown in Figure 4 Any visible
plaque was removed using the toothbrush so that
each experiment started with a totally clean set of tooth
surfaces
From day 2 until the end of each experiment the lower
buccal tooth surfaces were suhjected to a range of mechan-
ical 'treatments' using foam swahs and the remaining teeth
were brushed as 'normal' The lower huccal surfaces were
protected dunng brushing of the remainder of the teeth by
covering them with a finger This procedure occurred
whenever tooth cleaning was necessary, l e each morning
EQid evening and on occasions during the day when felt
appropnate On the last day of each expenment, after the
final cleaning procedure, plaque was disclosed again and
scored for the same sites as on day 1
In order to maximize the use of each experimental
penod, the lower buecal teeth were then re-treated using
a different mechanical procedure with a foam swah, and
a final plaque score was reeorded Each expenment was
then completed by cleaning any remammg plaque from
tbe expenmental area by using a tootbbrush
Treatments
The different 'treatments' used (swahhmg, scruhhmg and
'any') are descnhed helow
65
L S Pearson
Tooth Numbers 4 3
A C A A C A A C A A C A
Bnnh ( M a (bMalhw)
upper TMth
Lower TMtti
1st Post-TrMtmwH [ M a
Upper Teeltl
Lower Teeth
2tKl Post TrMtmant Data
Lower Teeth
Key A • Apptsxlmal C • Crevice
Figure 4 Data collection sheet
Foam swabs were moistened with tap water and the teeth
were wiped horizontally m both directions once with
sweeps across all the teeth in the experimental area, with
an effort being made to concentrate the action on the
plaque-accumulation sites under investigation This 'treat-
ment' was included to mimic the attention which the
plaque accumulation sites under investigation might
receive during mouth care in a clinical situation
Scrubbing
Foam swabs were moistened with tap water and a small
smear of toothpaste was added to the foam surface The
swab was then used with a mechamcal action which mim-
icked the use of a toothbrush This action was standardized
as follows The usual toothbrushmg procedure for the
experimental area was mentally observed and recorded
prior to the beginning of the expenments Each pair of
teeth m the lower buccal area received an average of 10
'too cuid fro' scrubbing movements along the tooth gingival
margin, after which a general scrub of the rest of the
smooth surface of each tooth took place hi order to mimic
this action, each tooth was scrubbed with a swab and
toothpaste (one forward and one backward motion m a
horizontal direction) 10 times along the tooth gingival
margin and then a general whole tooth scrub took place
while imagining that a toothbrush was bemg used
Any
This procedure took place after the previous treatments
and the penultimate plaque score had been recorded An
attempt was made to remove any remaining plaque m the
expenmental area by taking a swab and usmg any
66
Mid-Line
\/
2 1 1 2 3 4
NunttMT with plaqiw wora
A C A A C A A C A A C A > 1 2
movement to remove the visible plaque which was still
remaining, vnth the aid of a mirror
Plaque scoring system
The plaque sconng system used in this study was devel-
oped from the knowledge that plaque sconng systems are
commonly used m dental research to quantify the amount
of plaque visible at different sites The sconng procedure
used in this study was developed in order to measure the
amount of plaque at the two sites being studied, l e the
gingival crevice site and the approximal site It also incor-
porated an indication of the ability of the tool to remove
visible supra-gingival plaque completely, l e the best
performance of the tool
A score of 0 was given to sites at which no plaque dis-
closed was visible This score represents the desirable
score to maintain periodontal health
A score of 1 was given to any site with up to 1 mm of
plaque extending from the gingival margin or adjacent
tooth surface which was visible at any position withm that
site (gingival crevice or approximal sites) This score indi-
cated that ideal plaque removal had not been achieved
A score of 2 was given to any site v«th 1 mm or more
plaque at any point withm the site This score was an
mdication of how meffective the techmque/tool was
performing at that site
RESULTS
Figure 5 IS a photograph of the type of plaque accumu-
lation pattern which WEIS produced after 6 days of using a
toothbrush on the upper buccal surfaces of teeth and foam
© 1996 Blackwell Science Ltd, Joumal of Advanced Nursing, 23, 62-69
 ni,'JTioWjjg dental plaque

Approximaí plaque] Table 2 The ptircentage of sites with a plaque score of O at

different stages of each cxperimeiil

Experiment 1 : Swahs usedto cleau teetli iising a swabhing

technique

6 days later
ApproximalplaqueH
Brush Swahbing Any

Crevice , ^ ~^^—~
1
Figure 5 Plaque accumulations after 0 days of using foam swabs
Approximal (71 = 16]
Crevice (/i = 8)
94
100
0
0

Experiment 2: Swahs used to cleau teeth using a Hcruhhing

technique
0
75

to clean the lower hiic:cal teeth.

6 days later

Brush Scrubhiug Anv

swabs (swabbing or scrubbing] on tbo lower biiccai sur-
faces of teeth. Plaque has accumulated in crevice and
approximal areas of tlie lower bíK;cal .surfaces under inves-
tigation. In addition, plaque removal is incomplete at the
apex of one upper incisor, possibly as a result of the
unavoidable change in brushing tochniqiin which the
experimental area imposed (jn cleaning otber areas. The
first incisors either side of the mid-lino in the iower teeth
are porcelain caps. Although plaque i.s not extending up
tbe cap surfaces from the tooth gingival margin the gi ngivai
[irevice in these two sites was quite deep and contained
plaque wbicb was visible once removed using a dental
stick. The gingival tissue at these sites wa.s cyanosed and
glazed towards the end of the experimental period and
b!od easily during tooth brushing at the end of this period.
Gingival health was restored to normal for thes(! sites after
2 to 4 days of careful plaque removal with a toothbrush.
Plaque scores
Table 2 represents the results which were produced in one
series of the three experiments since a pooling of data
would result in losing the situation for individual cases.
Similar patterns of results were produced in each scries.
Experiment 1 was completed in triplicale and experiments
2 and 3 were completed in duplicate. Eacb of the eight
teeth under investigation in each experiment had three
plaque scorns, i.e. one crevice score and two approximal
scores (one at each side of the tooth]. In order to aid com-
parison of the figures, tbe results are given as the percent-
age of sitos in the experimental sample wbicb had a score
of 0, i.e, tbe desirable score and indicative of effective
plaque removal as a result of using the different mechan-
ical methods of cleaning and after the plaque had been
disclosed. The acitnal number of sites which give rise to
the percentage values are given as {n] after row headings.
Tbe total number of sites under investigation in eacb .series
Approximal (n==16] 100 0 0
Crevice (n = ñ) 100 0 63
Experimeut 3: The effect oí' using foam swabs on fi-day-old
plaque
H days later
6 day Swabhing Scrubhiug
Approximal (ÍJ = 1(:i] Ü 0 0
Crevice (ji = 8) 0 13 63
and replicate of tbe experiments was 24, i.e. eight crevice
sites and 16 approximal sites.
In experiments 1 and 2 tbe lefthand column contains
the two types of plaque-accumulation site under in-
vestigation, i.e. tbe approximal and the crevice sites. The
remaining columns represent the percentage of sites with
a plaque SL;ore of 0 at the beginning of the experiment (after
toothbrushing and then disclosure of plaque], after 6 days
of mechanical cleaning with swabs using a swabbing
(experiment 1] or a scrubbing (experiment 2] technique,
and finally after using any technique witb a swab to
remove visible plaque (both experiments].
The results for these two experiments are similar in tbat
at the beginning of the experiments most approximal and
crevice sites were plaque-free. After 6 days of using foam
swabs with either a swabbing technique (experiment 1
mimicking mouth care in a clinicai setting] or scrubbing
tecbnique (experiment 2 mimicking tootb brusbing) all
sites contained plaque. When 'any' technique was used
with the swab in an attempt to remove the remaining vis-
ible plaque it was possible to remove plaque from some of

© 1996 Blackwell Science Ltd, Journal of Advanced Nursing, 23, 62-69 67

L S Pearson
the crevice sites hut all of the approximal sites contained
visihle plaque
TVaiima to gingival tissue
It should he noted that although some degree of success
in terms of plaque removal was achieved using 'any' tech-
nique with the foam swahs, in practice this and the scruh-
hing technique occasionally traumatized the gingival
tissue as a result of the stick scraping across tissue through
the foam of the swah itself, which was very soft when
moist and produced little fnction or padding when moved
against the tooth gingival margin
Experiment 3 set out to investigate the efiect of using a
swah with a swahhmg and, after plaque disclosure, a scrub-
bing technique on more mature accumulated plaque This
was an attempt to mimic the efiect of these mouth care
procedures on a dirty mouth Plaque was allowed to
accumulate in the lower huccal site for 6 days
At the hegmning of the treatment procedure on day 6
none of the sites were clean when plaque was disclosed
(lefthand column)
After swahhmg with one standardized swabbing treat-
ment none of the approximal sites were clean and only
one of the eight crevice sites was clean (middle column)
After scruhbmg the remaining plaque sites, using one stan-
dardized scruhbmg treatment, none of the 16 approximal
sites were clean and two of the eight crevice sites were
clean
It IS worth noting that although these sites contained
more mature plaque of 6 days' accumulation and growth,
it was still uncalcified and loosely adherent in nature Euid
therefore not representative of some clinical presentations
requiring nursing care and intervention
DISCUSSION
The results from this study suggest that
1 the success of a suitahle toothhrush m removing plaque
IS affected hy user techmque hut that total visible
plaque removal was achievahle from the sites under
investigation,
2 foam swabs are not able to remove plaque fi'om some
'sheltered' areas of teeth and gingival crevices and that
total plaque removal was not achievable from the sites
under investigation
It has been demonstrated that this pattern of results —
1 e sometimes crevice plaque is removable by using foam
swabs hut sheltered approximal plaque remains maccess-
lhle to these swabs regardless of the technique employed
to access plaque — has been repeated each time the exper-
imental design has heen used in the replicates of these
experiments and also when used as class experiments with
students who have omitted their morning toothhrushmg
68 © 1996 Blackwell Science Ltd, Journal of Advanced Nursing, 23, 62-69
before the exercise (Pearson 1993) and m a clinical tnal
which IS currently in progress (Pearson & Tucker 1994)
Therefore, the results may he generalizahle to other simi-
lar quasi-laboratory type studies of plaque-accumulation
sites m 'healthy dentate adults' However, the findings of
the study, and those of previous studies which have sug-
gested or quoted that foam swahs are ineffective at
removing dental plaque, require careful translation mto
nursing practice
Other issues which have an impact on the choice and
delivery of 'quality care' and which are lnter-related
include the questions (a) what is the aim of each 'mouth
care' intervention, (b) what is the duration of the pre-
scnhed care, (c) what is the patient/client's personal pref-
erence, and (d) what is the risk of not performing effective
mouth c£ire'
What IS the aun of each mouth care intervention^
The £um of mouth care interventions may vary throughout
the day and night If care aims to moisturize the oral tis-
sues, foam swabs or a soft toothhrush will deliver moisture
to the tissues If care aims to clean actually the teeth, then
foam swahs are likely to he less effective than a small-
headed suitahle toothhrush used hy nurses who have
received instruction, practice and support in hrushmg the
teeth of those unahle to do so for themselves
Ln some instances the aim of the mouth care procedure,
whether delivered by a nurse, the clients themselves, or
canng relatives or fnends, may be to provide direct com-
fort through gentle oral stimulation withm that canng
relationship In these situations foam swahs or a soft
hahy-sized brush may be the best tool
What is the duration of the prescribed care?
If a person needs nurse-adnunistered mouth care
infrequently, and/or for a short penod which is less than
the time in which tissue damage may occur as a result of
accumulating plaque, then the use of foam swabs is likely
to cause nnnimal damage However, if a person is not able
to perform his/her ovim mouth care for a penod of time
which will result m tissue damage hy accumulations of
plaque, l e anything from 4 to 10 days m a healthy mouth
and more rapidly in areas which already house accumu-
lations of plaque, then there is a risk of causing the person
harm if effective plaque removal measures are not used
What IS the patient/client's personal prefierence''
People have different standards for their own mouth care
and this needs to be considered when plannmg care The
collection of information relating to the current standard
and desired standard of oral health withm the context of
an informed choice of care would form a useful framework

for planning and delivering mouth care to people m the
many situations in which it may be reqmred
What is the nsk of not performing effective mouth
care?
In some situations there is a risk attached to the develop-
ment of plaque m a person's mouth and this will affect the
advice given and the negotiation and/or tnal of tools for
care Plaque-control measures may need expanding in the
care of a number of people, e g those who have an
impaired immune response which allows overgrov»rth and
invasion of plaque organisms through the gmgivae and
other tissues, those whose teeth and gingivae are consist-
ently inaccessible to plaque-removal measures, those who
are at nsk of developing further problems if plaque organ-
isms gam access to the circulatory system and adhere to,
and grow in, other tissue surfaces within the body
CONCLUSION
This paper presents the results of work which suggest that
foam swabs are ineffective at removing dental plaque from
some areas of tooth/gingival, tooth/tooth margins, and
highlights the impact that these findings may have on some
areas of nursing practice
The study method requires replication on a larger
sample of people in order to increase confidence m the
findings and to allow for further and more rigorous
statistical testing
Further studies which aim to expand our understanding
and knowledge base of the different aspects of nurse-
admimstered mouth care would serve to mform and
underpin responsive and high-quality care
References
Addy M , Slayne M A & Wade W G (1992) The formation and
control of dental plaque an overview Journal of Applied
Bactenology 73, 269-278
Armitage G G , Dickenson W R , Jenderseck R S , Levme S M &
Ghambers D W (1982) Relationship between the percentage of
subgingival spirochetes and the seventy of penodontal disease
Journal of Penodontology 53, 550-556
Glarke G (1993) Mouth care and the hospitalized patient Bntish
Journal of Nursing 2(4), 225-227
DeWalt E M (1975) Effect of tuned hygienic measures on oral
mucosa in a group of elderly subjects Nursing Research 24,
104-108
DeWalt E M & Hames A K (1969) The effects of specific Stressors
on healthy oral mucosa Nursing Research 18, 22-27
Donoghue H (1987) A mouthful of microbial ecology New
Scientist, 1546, 61-65
Greene J G & VemiiUion M P H (1960) The oral hygiene index a
method for classifymg oral hygiene status The Journal of the
Amencan Dental Association 61, 172-179
Hams M D (1980) Tools for mouth care Nursing Times 76(8),
340-342
© 1996 Blackwell Science Ltd, Journal of Advanced Nursing, 23, 62-69
Removing dental plaque
Howarth H (1975) A Study of Mouth Care Procedures Carried
Out by Nurses for the Very III Person Unpubhshed MSc thesis
(no 5702) Manchester University, Manchester
Howarth H (1977) Mouth care procedures for the very ill Nursing
Times 73, 354-355
Hunt M (1987) The process of translating research findings mto
nursing practice Journal of Advanced Nursing 12, 101-110
Lewis IA (1984) Developing a research-based curriculum an exer-
cise m relaUon to oral care Nurse Education Today 3(6), 143-144
Loe H (1963)Epidemiology of penodontal disease An evaluation
of the relative significance of the aetiological factors in the light
of recent epidemiological research Odontologtsk Tidsknft 71,
479-503
Loe H , Theilade E & Jensen S B (1965) Expenmental gingivitis
in man Journal of Penodontology Z6. 177-187
LoescheWJ & Syed S A (1978)Bactenology of human gingivitis
effect of plaque and gingivitis score Infection &• Immunity 21,
830-839
Marsh P & Martin M (1992) OraiMjcrofajo/og}'3rd edn Ghapman
& Hall, London, pp 6-25
Miller R & Rubinstein L (1987) Oral health care for hospitalized
patients the nurse's role Journal of Nurse Education 26(9),
362-366
Page R G & Schroeder H E (1976) Pathogenesis of lnfiammatory
penodontal disease Laboratory Investigation 33, 235-249
Palenstem Helderman, van W M (1981) Longitudinal microbial
changes in developing human supragingival and subgingival
plaque Archives of Oral Biology 26, 7-12
Pearson L S (1993) Studies of dental plaque composition,
accumulation and removal possible uses in research based
teaching European Gonference on 'New Initiatives m Nursing
and Midwifery', University of Durham, Durham, 24-25
September
Pearson L S & Tucker R (1994) A comparison of the ability of
foam swabs and toothbrushes to remove dental plaque a clini-
cal tnal RCN Annual Nursing Research Conference, Hull,
8-10 April
Pntchard A P & Mallet J (ed ) (1992) The Royal Marsden Hospital
Manual of Clinical Nursing Procedures 3rd edn BlackweU
Scientific Publications, Oxford, pp 301-307
Russell A L (1967) Epidemiology of penodontal disease
International Dental Journal 17, 282-296
Schei O , Waerhaug J , Lovdal A & Amo A (1959) Alveolar bone
loss as related to oral hygiene and age Journal of Penodontology
30, 7-16
Socransky S S (1970) Relationship of bactena to the etiology of
penodontal disease Journal of Dental Research 49, 203-222
Theilade E, Wnght WH., Jensen SB & Loe H (1966) Exp«i-
mental gmgivitis m man n A longitudinal chnical and bacteno-
logical mvesUgation Journal of Penodontal Research 1, 1-13
Tipler L S (1984) Studies of Bactenal Populations Associated
with the Onset and Progression of Chronic Penodontal Disease
in Humans Unpublished PhD thesis, Liverpool University,
Liverpool
Trenter Roth P & Greason N S (1986) Nurse administered oral
hygiene is there a scientific basis' Journal of Advanced Nursing
11, 323-331
Watson R (1989) Gare of the mouth Nursing 3(44), 20-24
Wiley S B (1969) Why glycerol and lemon juice' Amencan
Journal of Nursing 69, 342-344
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