CLINICAL REPORT
Australian Dental Journal 2002;47:(2):170-173
Maintenance of mouth hygiene in patients with oral cancer
in the immediate post-operative period
A Chandu,* C Stulner,* AM Bridgeman,* ACH Smith*
Abstract
Background: Little has been written about mouth
hygiene measures during the immediate post-
operative phase in patients with oral cancer. Mouth
hygiene not only involves the care and maintenance
of the dentition and its related structures, but also
the maintenance of surgical sites, reconstructive
techniques such as free flaps and generally keeping
the mouth clean, which may optimize healing
potential and patient comfort. Ward conditions and
novel methods of reconstruction require innovation
and improvisation of routine methods of mouth and
oral hygiene.
Methods: A review of techniques of mouth hygiene
used during the immediate post-operative phase by
our unit over the last nine years and a review of the
literature.
Results: Various methods gained from our
experience in treating patients with oral cancer at
the Austin and Repatriation Medical Centre are
documented. Most methods involve a combination
of either chlorhexidine or normal saline mouth
rinses and mechanical cleaning.
Conclusions: There are many different methods of
mouth care in patients who have had resection for
oral tumours. It is important for dental practitioners,
hygienists and allied health professionals, who may
be involved with care of such patients to have an
understanding of the methods that are available and
appropriate for such patients.
Key words: Oral cancer, hygiene, post-operative.
(Accepted for publication 15 March 2001.)
INTRODUCTION
Mouth hygiene in the immediate healing phase in
patients who have undergone resection for oral
tumours is frequently overlooked. The reasons for this
are many. For most of these patients, mouth hygiene is
only possible by the action of nursing staff and allied
health professionals who may have limited time to
assist. There may also be a lack of dentally trained staff
for education of patients and the provision of some
form of maintenance. Patients may be non-compliant
*Oral and Maxillofacial Surgery, Austin and Repatriation Medical
Centre, Heidelberg, Victoria.
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or too unwell to implement mouth hygiene and most
wards have inadequate and inappropriate apparatus for
mouth hygiene.
The term mouth hygiene in these patients not only
includes oral hygiene, i.e., the removal of dental plaque
from teeth and the associated oral structures, but also
the removal of retained food due to impaired
swallowing mechanisms and secretions such as saliva
or blood which maybe either fresh or coagulated on
oral structures. Inadequate mouth hygiene in these
patients can increase patient discomfort and may
predispose to complications such as infection of
surgical wounds, or inflammation and infection of the
surrounding oral tissues, such as gingivitis or mucositis.
Self-administration of mouth hygiene by patients can
be difficult and sometimes inappropriate on the ward.
Patients recovering from major surgery are initially
non-ambulant, incapable of personal hygiene measures
and this is especially true of the Intensive Care Unit
(ICU). Intravenous lines, pulse oxymeters and wound
dressings including backslabs may mechanically
obstruct the patient from cleaning. Incision lines, skin
and bone grafts, local and free vascularized flaps
should initially be maintained by nursing staff as
inappropriate techniques may be deleterious for wound
healing. Such allied staff need to be instructed on
appropriate techniques for mouth hygiene maintenance
and the education of patients. Dentally trained
professionals, including dental hygienists, may also
need guidance in regards to appropriate techniques for
these patients who have had complex operative
procedures where traditional oral hygiene techniques
may be inappropriate and may increase morbidity.
Thus, the aim of this paper is to describe various
simple techniques for maintaining adequate mouth
hygiene in patients who have undergone resection for
oral cancer that can be easily implemented on the ward
without the need of dental instruments or trolleys.
Methods of mouth hygiene and pre-operative
treatment
Mouth hygiene can be achieved via mouth rinses or
mechanical removal. The choice of technique may be
determined by the number of days the patient is
Australian Dental Journal 2002;47:2.
post-operative, the procedure undertaken, whether the
patient is dentate or edentulous, the status of the
dentition and the nature of enteral intake. It is highly
desirable for patients undergoing major resection to
have pre-operative supra- and sub-gingival calculus
removal and oral hygiene instruction given to ensure a
clean operating field. Simple restorative procedures
should also be completed if possible. Teeth in the
operating field and those requiring complex treatment
are generally removed peri-operatively. There should be
no delay in the treatment of oral cancer as some
tumours have a propensity for rapid growth. The
treatment plan should be made in conjunction with the
treating oral and maxillofacial surgeon. This avoids
any unwanted treatment for teeth that may be included
in the resection. These procedures are especially
important for those patients who are retaining teeth
post-operatively and are undergoing radiotherapy.
Mouth rinses
Gargling with mouth rinses is appropriate after one
to two days for patients with small tumours, which
have been locally excised and primarily closed, and five
days for patients who have had major resections. For
patients with free flaps, seven days is more appropriate.
Before this, wounds and oral structures can be cleansed
with large cotton buds dipped in appropriate mouth
rinses. Gargling mouth rinses should be used with
caution in those patients with dysphagia or impaired
swallowing and gag reflexes post-operatively. These
patients should be assessed by a speech pathologist
prior to prescribing gargling.
Normal saline
Normal saline is ubiquitous and can be used in any
situation. It is cheap, easy to make up and is readily
available. Normal saline gargles cleanse the wounds,
reduce swelling and can decrease pain. Cotton buds
and toothbrushes can be used with saline to clean the
dentition if gargles are not appropriate. Saline is
particularly indicated for patients who have had
cutaneous free flap reconstruction. Such patients often
accumulate keratin debris which should be carefully
removed from flap surfaces and wound edges to aid
with healing and flap observation.
Chlorhexidine
Chlorhexidine gluconate has been widely tested and
extensively used over the last 20 years as a surgical
preparation solution, scrub lotion and mucosal
disinfectant. It has been shown to have a broad
spectrum of topical anti-microbial activity against gram
positive and gram negative bacteria and fungi, and also
demonstrates substantivity, which is the ability to
prolong its effect after use by adsorbing to oral
structures.1 Its effectiveness in preventing the formation
of plaque and gingivitis and promoting healing of
surgical wounds in periodontal and implant surgery has
been well reported in the literature.2-6 In patients who
Australian Dental Journal 2002;47:2.
have undergone major resection, chlorhexidine can be
used to keep wounds clean, prevent marginal gingivitis
and prevent secondary infection of apthous ulceration,
both of which can occur in these patients. It can be used
immediately post-operatively with cotton buds or soft
toothbrushes for the dentition or as gargling mouth
rinses at the five day stage. Possible side effects include
brown staining of the dentition (removable with dental
prophylaxis), hypogeusia, dysgeusia, burning sensation
on the oral soft tissues, desquamative and ulcerative
lesions of the oral mucosa which may contraindicate its
use in patients who have undergone cutaneous free flap
reconstruction.7 This, though, seems to be more a
theoretical contra-indication as chlorhexidine clinically,
in low concentrations, causes minimal problems in such
patients.
Chlorhexidine is most commonly available as a 0.2
per cent solution. However, it has been proven that a
0.12 per cent solution is just as clinically effective in the
prevention of gingivitis, and reduces the incidence of
side effects.8,9 Hence it is recommended that a 1:1
dilution with water be prepared for mouth hygiene use.
Chlorhexidine can also be applied to the oral cavity in
a gel form (0.2 per cent) using a cotton bud. Not only
will this have an antibacterial effect in regards to
wound care, but it has been shown to reduce caries risk
associated with streptococci and lactobacilli in patients
who have had radiotherapy to the head and neck
region.10
It has also been shown recently that dental plaque
can harbour nosocomial pathogens which may lead to
the development of pneumonia11 and that those patients
in the ICU setting may be most vulnerable to this
occurring. Chlorhexidine gel (0.2 per cent) has been
shown to decrease bacterial colonization in such
patients and may also decrease the incidence of
nosocomial infections in ICU patients who are
mechanically ventilated.12 This has implications for
patients having resection for oral cancer as they
invariably spend some time in ICU before being
discharged to a general ward and it is here that oral
hygiene measures should be commenced.
Povidone iodine
Povidone iodine has been found to significantly
reduce the incidence of post-operative wound
complications in surgery of the oral cavity and
oropharynx.13 It is useful for mucosal infections but
does not inhibit plaque accumulation and should not be
used for periods longer than 14 days since a significant
amount of iodine is absorbed. It is contraindicated as a
regular mouth wash in patients with thyroid disorders
or on lithium therapy. Side effects include mucosal
irritation and hypersensitivity reactions.14
Hydrogen peroxide
In patients with gross plaque deposits, 3 per cent
hydrogen peroxide solution in a 1:1 dilution with water
may be useful. As well as being an effective oxidizing
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Fig 1. Some commonly used items for maintaining mouth hygiene
within the ward setting. (From left to right: Yankaur sucker, large
swabs, chlorhexidine and gauze squares.)
agent against anaerobic bacteria, it also has a
mechanical cleansing effect due to frothing when in
contact with oral debris.14 Dilute solutions may be
appropriate for cleansing established wound
dehiscences where debris accumulation is a concern
(due to the effects of gravity). Adequate suction is
required to remove the froth.
Anaesthetic mouth rinses
These commonly contain either benzocaine
cetylpyridinium chloride (Cepacaine, Hoechst Marion
Roussel, Lane Cove, NSW) or benzydamine hydro-
chloride, e.g., Difflam™ (3M Pharmaceuticals,
Thornleigh, NSW), which are quaternary ammonium
compound anti-inflammatory agents, in a hydroalcoholic
base. Difflam is also available as a chlorhexidine
containing solution called Difflam-C. This would be
the preferred solution for those patients with mucosal
pain. However, this is not routinely stocked in hospital
pharmacy departments. These rinses may be useful in
patients who have had surgery after radiotherapy and
have persistent mucositis. One should not forget the
various lignocaine containing preparations.
Listerine™
Listerine™ (Warner Lambert Healthcare, Caringbah,
NSW) contains a combination of phenol-related
essential oils, thymol, eucalyptol, menthol and may
also have methylsalicylate in a hydroalcoholic vehicle,
depending on which Listerine product is being used.
There have been extensive clinical studies, which
demonstrate reductions in plaque accumulation and
gingivitis.15,16 However, in comparison to chlorhexidine
it does not demonstrate substansivity, is less effective,
more expensive and more irritating to oral tissues.
Hence, its use in such a patient group is not
recommended.
Mechanical methods of mouth hygiene
This includes readily available items on the ward
such as suction devices, gauze and cotton swabs (Fig 1).
Dental floss, toothpicks, soft toothbrushes, subgingival
172
irrigating devices and electric toothbrushes are only
useful in dentate patients, are not readily available on
wards and can be expensive.
Suction
A Yankaur sucker and a flexible suction catheter is
invaluable for removing pooled saliva, blood, mucous,
pus and any other oral secretions. Pooling of secretions
can particularly occur in patients with impaired
swallowing mechanisms associated with tongue or
pharyngeal resections. This is uncomfortable for the
patient and can predispose to drooling. Caution should
be used, though, in areas where free flaps or skin grafts
have been placed. Occasionally, patients require
assistance with excessive pooled saliva but most are
able to cope with self administration.
Gauze and cotton buds
Gauze and large cotton buds can be used to crudely
remove gross plaque deposits and secretions such as
coagulated blood and saliva. Both should be wet with
chlorhexidine or saline before intra-oral usage to prevent
sticking and damaging wounds. Use of chlorhexidine
topically may also reduce bacterial loads in patients
who cannot gargle or who have an impaired swallowing
mechanism. Large cotton buds are more precise for
cleaning posteriorly and are less likely to cause trauma
or damage to incision lines, wounds and flaps.
Toothbrushes
Toothbrushes should only be used in dentate
patients. Patients with manual toothbrushes may
require assistance in the initial post-operative phase.
Intravenous lines, arterial lines, pulse oxymeters, blood
pressure cuffs can prevent patient brushing. This is
especially true of patients with radial forearm free flaps
as backslabs can be used as part of the dressing for the
donor site, making brushing a difficult task. Brushes
with soft bristles are preferred as these cause potentially
less damage to oral soft and hard tissues. Several
different techniques of toothbrushing are described,17
but the more appropriate in this patient group are the
simplest to teach and perform. For this reason the Bass
technique is recommended.18 The toothbrush is placed
at 45 degrees onto the teeth and the gingival margin
and the bristles are gently pressed to enter the gingival
sulcus. Cleaning is achieved via short strokes described
as a back-and-forth horizontal jiggle or vibratory
action. The benefits of this technique include; it can be
done with patients who have restricted arm movements
and it can be carried out by allied health practitioners
in the initial phase. Toothbrushes may be used with
chlorhexidine or saline initially. Dentrifices have the
added benefits of fluoride delivery for caries prevention
but should only be used once the patient is ambulant,
has satisfactory oral muscle movement and has an
adequate gag reflex due to risk of aspiration and
inability to expectorate the dentrifice. The gold
standard for mechanical removal of plaque is an
Australian Dental Journal 2002;47:2.
oscillating electric toothbrush such as those provided
by Braun/Oral B (Braun AG, Frankfurt, Germany).
Such instruments should be kept away from incision
lines and flaps.
Free flaps
Free vascularized tissue transfer, or free flaps, have
revolutionized oral reconstruction following ablative
operations for oral cancer. Most of these ablative
procedures produce complex composite defects of the
oral cavity, and reconstruction requires composite free
flaps containing a combination of tissues including
skin, fascia, nerves, muscle, fat and/or bone. The choice
of free flap depends on the site and nature of the defect,
and most have their surfaces continuously bathed in
oral fluids, thus requiring attention to hygiene.
In the immediate post-operative period, the surface
of the flap should be gently swabbed to remove
accumulated debris and facilitate viability monitoring.
Commonly patients remain nil by mouth in the early
post-operative period, predisposing to tongue coating
and stasis of surface epithelial debris secondary to lack
of mechanical passage of food. This is especially the
case with the skin surface of flaps. Gentle swabbing
three to four times a day adequately substitutes for the
mechanical debridement achieved by mastication and
the passage of food during this time. If the patient is
going to remain nil by mouth for an extended period,
they should be instructed on the use of the types of
mechanical aids previously discussed.
CONCLUSIONS
The methods described in this paper are derived from
treating over 100 patients with oral cancers by Oral
and Maxillofacial Surgery at the Austin and
Repatriation Medical Centre over the past nine years.
Although, some of the techniques described are
common sense, some direction in regards to
appropriate methods of hygiene need to be mentioned,
especially in regards to oral reconstructive procedures.
Dental practitioners, hygienists and allied health
practitioners will be called upon to look after patients
with oral cancer in the hospital setting. We are keen to
see an increased role, particularly that of hygienists and
dentists in the maintenance and education of both
patients and staff on this topic. An insight into the
various methods of mouth hygiene maintenance that
are appropriate in the ward setting may decrease the
risk of post-operative complications and may also
improve the post-operative comfort for the patient.
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Address for correspondence/reprints:
Associate Professor Andrew Smith
School of Dental Science
The University of Melbourne
711 Elizabeth Street
Melbourne, Victoria 3000
Email: andrew@wisdom.smith.com.au
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