How to undertake effective mouth care and oral assessments
Intended for healthcare professionals
how to series    

How to undertake effective mouth care and oral assessments

Richard Hatchett Senior nurse editor, RCNi, London

Why you should read this article:
  • To recognise the importance of mouth care in promoting oral health and comfort, and preventing or treating disease

  • To enhance your understanding of the procedure for undertaking an effective oral assessment and mouth care

  • To identify oral health interventions that could be used in patients with severe oral conditions

Rationale and key points

Mouth care is an essential aspect of a patient’s overall oral hygiene. Nurses may be required to undertake an oral assessment and/or mouth care in a variety of healthcare settings, including hospitals, residential care or in patients’ homes. Therefore, they must ensure they have the knowledge, confidence and skills to do so effectively, while ensuring they work within the limits of their competence. The patient and their family and/or carers should be supported to be involved in mouth care where appropriate. This will enable them to develop the ability to monitor and maintain the patient’s oral hygiene.

• Any oral assessment and/or mouth care provided should be person-centred and include the use of a reliable and locally approved oral assessment tool. The frequency of any mouth care will depend on the outcomes of the assessment and the patient’s needs.

• It is important for the nurse to understand the various factors that can result in suboptimal oral hygiene and to reduce these where possible.

• Nurses should take an evidence-based and standardised approach to care by accessing the clinical guidelines available for mouth care and severe oral conditions such as mucositis. These guidelines detail interventions such as the use of mouthwash for moistening the oral cavity or providing pain relief.

Reflective activity

‘How to’ articles can help to update your practice and ensure it remains evidence-based. Apply this article to your practice. Reflect on and write a short account of:

• How this article might improve your practice when undertaking mouth care.

• How you could use this information to educate nursing students or your colleagues on the appropriate technique and evidence-base to maintain the patient’s oral hygiene.

Nursing Standard. doi: 10.7748/ns.2021.e11756

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

@RCNi_Richard

Correspondence

richard.hatchett@rcni.com

Conflict of interest

None declared

Hatchett R (2021) How to undertake effective mouth care and oral assessments. Nursing Standard. doi: 10.7748/ns.2021.e11756

Disclaimer

Please note that information provided by Nursing Standard is not sufficient to make the reader competent to perform the task. All clinical skills should be formally assessed according to policy and procedures. It is the nurse’s responsibility to ensure their practice remains up to date and reflects the latest evidence

Published online: 20 September 2021

Mouth care is required by patients in a range of healthcare settings, including hospitals, residential care and the patient’s home. Mouth care refers to various interventions that cleanse and monitor the oral mucosa, lips, teeth and gums, with the aim of promoting oral health and comfort, and preventing or treating disease (Argenio-Haines et al 2020). Oral health has been defined as ‘a state of being free from mouth and facial pain, oral diseases and disorders that limit an individual’s capacity in biting, chewing, smiling, speaking and psychosocial well-being’ (World Health Organization Regional Office for Europe 2021).

In normal health, optimal oral hygiene through self-care is relatively easy to achieve. Most people brush their teeth and/or use mouthwash regularly to maintain their oral hygiene, while an optimal fluid intake can clear debris and particles of food from the mouth. However, during ill health, barriers to effective oral hygiene can develop quickly.

Such barriers include reduced ability to self-care due to weakness and/or lack of motivation, alongside a suboptimal diet and inadequate hydration. In addition, some medicines such as inhaled corticosteroids can result in oral diseases such as candidiasis (a fungal infection that can affect the mouth), while being in an unfamiliar environment such as a hospital or new residential care home may mean the individual cannot undertake their usual self-care routines. Furthermore, some treatments such as specific chemotherapies, radiation or targeted cancer therapies can lead to painful oral conditions such as mucositis. Oral mucositis is inflammation of the mucosal membrane, causing pain and dysphagia (swallowing difficulties), affecting the individual’s ability to talk (Quinn et al 2020).

Ineffective mouth care can lead to the accumulation of plaque on the teeth or dentures. Dental plaque is composed of bacteria and can cause inflammation of the gums (gingivitis), and if left untreated can develop into periodontitis, a gum disease that can begin to destroy the tissues and bones in the jaw that support the teeth (Doshi et al 2021). Chronic inflammation in the mouth can lead to inflammation elsewhere in the body, with oral bacteria being absorbed by inflamed gums before travelling in the bloodstream, which subsequently risks the development of sepsis (Van Dyke and van Winkelhoff 2013, Doshi et al 2021).

The risk of patients developing conditions such as gingivitis and periodontitis, as well as the associated risk of systemic infection, demonstrate the importance of nurses having the skills required to prevent suboptimal oral hygiene. These skills include assessing the patient’s oral status and undertaking regular evidence-based mouth care. These measures will ensure patient comfort, as well as contributing to disease prevention and effective treatment.

When undertaking person-centred mouth care, nurses will need to pay particular attention to certain patient groups, including (Health Education England 2019a, Argenio-Haines et al 2020):

  • Patients who find it challenging to take fluids and/or maintain their oral hygiene, for example due to pain, immobility or restricted movement as a result of conditions such as arthritis.

  • Patients who are ‘nil by mouth’.

  • Patients who are experiencing vomiting.

  • Patients who are receiving oxygen therapy, which can have a drying effect.

  • Patients who develop a dry mouth due to mouth breathing (where an individual breathes primarily through the mouth and not the nose), which is a common sign of respiratory conditions such as exacerbation of asthma, enlarged tonsils or seasonal allergies.

  • Patients who are receiving mechanical ventilation.

  • Patients with a specific pathology such as stomatitis (general inflammation of the oral tissues), oral mucositis and/or oral candidiasis.

  • Patients who have experienced trauma involving the jaw, mouth or teeth, or have undergone maxillofacial surgery.

Mouth care should be undertaken at least twice per day, or more frequently if required. Tooth brushing should typically take place twice per day, including once before bedtime. However, the required frequency for undertaking mouth care should be individualised and based on a thorough oral assessment of the patient, using an accredited tool such as the Brief Oral Health Status Examination (BOHSE) (Australian Institute of Health and Welfare 2009). Any oral assessment tool and subsequent mouth care also needs to consider person-centred factors such as the patient’s comfort and their ability to self-care.

Preparation and equipment

  • Oral assessment and mouth care is a personal and invasive procedure; therefore, nurses and nursing associates must ensure their knowledge and skills are up to date, and they work within the limits of their competence (Nursing and Midwifery Council 2018).

  • The nurse should ensure they have allocated sufficient time to undertake the procedure comfortably, and the oral assessment and mouth care is undertaken in a private environment.

  • The nurse should explain to the patient that they intend to undertake an oral assessment and/or mouth care, what this entails and the rationale for this procedure. They should then obtain informed consent for the procedure from the patient. It is important the nurse does not simply inform the patient that they are going to begin mouth care, because this can make it challenging for the patient to refuse and they may not feel involved in the procedure.

  • Where possible, the nurse should involve the patient and their family and/or carers in the procedure so that they may feel empowered to undertake it themselves in the future.

  • Before starting an oral assessment and/or mouth care, the nurse should agree a signal with the patient, such as raising their hand, that will indicate the patient wants to halt the procedure. Even where the patient is unconscious, or appears to be unconscious, the nurse should still explain the mouth care procedure. This is because the patient’s hearing may be intact and the sudden commencement of mouth care without explanation could be startling.

  • The nurse should gather the appropriate personal protective equipment (PPE) required by their local policy for personal care and potential contact with body fluids. This PPE may include a disposable apron, clean disposable gloves, a face mask and eye protection.

  • The nurse should ensure all the required documentation is available.

  • An oral assessment and/or mouth care can be undertaken in the hospital, residential care or home environment, so the nurse may need to liaise closely with the patient and their family and/or carers to maintain adequate stocks of mouth care equipment.

  • The nurse should collect all the necessary equipment on a mouth care tray, if their healthcare organisation does not provide a pre-packed single-use mouth care tray. While the equipment used for the procedure will vary, it typically includes:

    • An effective light source, such as a pen torch or angle-poise lamp.

    • Disposable pad.

    • Disposable tongue depressor.

    • Gauze swabs.

    • Cup or beaker of water.

    • Small-headed toothbrush with a soft or medium texture. A smaller or paediatric toothbrush may be used in patients who are experiencing oral pain.

    • Access to running tap water to rinse and remove debris from the toothbrush. In cases where running tap water is not available in the immediate vicinity – for example where the patient is in their bedroom at home – a receptacle or bowl may be used to hold clean water for rinsing the toothbrush.

    • Fluoridated non-foaming toothpaste. This toothpaste does not contain the foaming agent sodium lauryl sulphate so it may be suitable for use in patients with dysphagia and/or those at risk of choking. This type of non-foaming toothpaste may require a prescription.

    • Labelled denture pot containing clean, warm water, as well as a denture cleaner, if required.

    • Dental floss or tape.

    • Moisturising gel such as petroleum jelly.

    • Bland rinses such as water, salt water or 0.9% sodium chloride solution.

    • Disposable paper towels.

    • Clinical waste bag.

  • The use of oral foam swabs or sticks is generally not recommended in mouth care. They have limited effectiveness in removing plaque or debris and can be a choking hazard if the foam head becomes detached or is bitten off by the patient. However, local policy may state that a single-use foam swab or stick dipped in water can be used to moisten the patient’s lips and gums, for example.

Procedure

Oral assessment

  • 1. The patient’s oral health should have been assessed, and any issues identified, on their admission to hospital or a residential care setting. Oral assessments should be repeated periodically during the patient’s treatment episode to evaluate any mouth care or oral health interventions.

  • 2. When undertaking an oral assessment, use a reliable and validated locally approved tool, for example the BOHSE (Australian Institute of Health and Welfare 2009). This ensures the oral assessment is undertaken systematically, no elements are missed and that all findings are recorded so that the patient’s improvement or deterioration can be monitored. Using the same validated tool also ensures a standardised approach is taken by the various practitioners involved in the patient’s care. Whichever tool is used, ensure you are familiar with it and trained in its use.

  • 3. Decontaminate your hands in accordance with local policy. Put on a disposable apron and any other appropriate PPE, and put on clean disposable gloves.

  • 4. Sit level with the patient – who should be in an upright position if possible – and use an effective light source such as a pen torch or an angle-poise lamp when inspecting the mouth.

  • 5. If the patient is wearing dentures, ask them to remove these. If the patient requires assistance, slide a gloved finger along one or either side of the dentures, gently break the seal, and lift them out of the patient’s mouth. Place the dentures in a labelled denture pot containing clean warm water.

  • 6. Offer the patient a cup or beaker of water to rinse out their mouth.

  • 7. Use a disposable tongue depressor to gently press down the patient’s tongue to ensure their entire mouth is visible. The tongue depressor can be wrapped in gauze to make the inspection more comfortable for the patient, particularly if their mouth is dry or sore. You can also ask the patient to stick out their tongue and raise it, for maximum visibility when inspecting the obscured underside of the tongue and the floor of the mouth. Box 1 describes the areas of the mouth that should be inspected during an oral assessment.

  • 8. If possible, ask the patient some questions about their oral health, such as whether they are experiencing any bleeding or painful areas, challenges in eating and/or drinking, or issues such as dry mouth, inadequate or excessive saliva production, and/or changes in taste.

Box 1.

Areas of the mouth that should be inspected during an oral assessment

  • Lips – should be pink, moist and intact. They should not be dry, peeling, swollen or blistered

  • Tongue – should be pink, moist and clean. It should not be swollen, red, ulcerated or coated

  • Gums – should be pink, moist and firm. They should not be bleeding or inflamed, or have an unpleasant odour (halitosis)

  • Mucosa (on the cheeks, palate and under the tongue) – should be pink, moist, intact and smooth

  • Saliva – should be of a ‘watery’ consistency and white or clear in colour

  • Teeth – should be white and firm, with no debris or decay

  • Dentures – should be clean and comfortable

(Adapted from Welch 2017, Health Education England 2019b)

Mouth care

  • 1. Place a disposable pad under the patient’s chin to protect their clothing.

  • 2. If mouthwash is to be used, offer it before brushing the patient’s teeth. This is so that the mouthwash will not wash away the toothpaste after brushing. It is important that some residual toothpaste remains on the patient’s teeth and the surface of the mouth after brushing because it offers protection due to the fluoride content, which strengthens tooth enamel and reduces levels of acid and bacteria.

  • 3. To assist in maintaining the patient’s oral hygiene, bland rinses such as water, salt water or 0.9% sodium chloride solution may be administered for them to ‘swill and gargle’ 2-4 times per day. This will assist in clearing any debris from the mouth. Again, any rinses should be administered before brushing and not afterwards because it is important not to rinse away any residual toothpaste.

  • 4. Rinse a small-headed toothbrush in water and apply a small pea-size amount of fluoridated non-foaming toothpaste on to the toothbrush. Support the patient to clean their mouth with the toothbrush or undertake this for them if they are unable to do so.

  • 5. Clean the patient’s tongue and teeth using gentle small circular motions of the toothbrush for at least two minutes.

  • 6. Ask the patient to spit out the toothpaste and offer them a disposable paper towel to use to wipe their mouth, assisting them where necessary.

  • 7. Reinspect the patient’s mouth and evaluate the effectiveness of the mouth care, undertaking further cleaning as required.

  • 8. Rinse the toothbrush thoroughly in running water and store it upright to drain.

  • 9. Assist the patient to floss between their teeth or undertake this for them if they are unable to do so. Tear off a length of dental floss or tape, wrapping this around one finger on each hand and using a ‘see-saw’ action to clean between the patient’s teeth. Do not undertake flossing if the patient’s gums are already bleeding because flossing could cause or exacerbate bleeding, particularly where there are issues with coagulation such as the use of anticoagulant medicines. Dispose of the used dental floss or tape in the clinical waste bag.

  • 10. If the patient has dentures, clean these with warm water, a toothbrush and a specific denture cleaner, rather than toothpaste. Rinse the dentures thoroughly after cleaning, and assist the patient to place them back in their mouth.

  • 11. Apply a small amount of moisturising gel such as petroleum jelly to the patient’s lips and wipe away any excess with a disposable paper towel or gauze pad.

  • 12. Clear all of the equipment away and ensure the patient is comfortable.

  • 13. Dispose of the PPE and decontaminate your hands in accordance with local policy.

  • 14. Document fully the oral assessment and mouth care undertaken, and escalate any concerns to senior nursing, medical or dental staff as appropriate.

Interventions for patients with severe oral conditions

There are certain oral conditions that may require intensive oral health interventions due to their severity; for example, trauma, severe stomatitis (inflammation of the mucous membrane of the mouth) and mucositis. These conditions can be physically and psychologically debilitating and may adversely affect the patient’s everyday activities, notably their ability to eat and drink and interact socially. In these cases, the nurse can consider the following interventions:

  • Ensure a specific multidisciplinary oral treatment plan for the patient is in place and followed.

  • Regularly assess and record the patient’s pain using a validated tool and prescribe appropriate topical and/or systemic analgesics where necessary (Myatt 2021). Patient-controlled analgesia may also be considered in some cases. One example of a medicine with a specific use in oral health is benzydamine hydrochloride, a non-steroidal anti-inflammatory drug that is available as a mouthwash or spray to soothe mouth ulcer pain.

  • Use mucosal protectants (medicines that form a protective coating or gel on the mucosal lining, particularly in ulcerated areas), which can reduce pain.

  • Use mouthwashes, which may be clinically indicated for oral hygiene, preventing or treating infection, moistening the oral cavity or providing pain relief.

  • If the patient’s eating and/or swallowing is compromised due to pain, involve other members of the multidisciplinary team such as a dietitian to undertake a nutrition assessment and make appropriate dietary recommendations.

  • At an early stage in the patient’s care, use screening and provide support to identify and manage any adverse psychological effects of severe oral conditions.

Evidence base

Evidence-based mouth care is informed by various guidelines. These provide general advice for oral health in care homes (National Institute for Health and Care Excellence (NICE) 2016), aim to prevent the development of oral health conditions such as periodontitis (Public Health England 2017), and promote person-centred mouth care in hospitals (Health Education England 2019a, 2019b). Specific guidance for mouth care in conditions such as oral injury resulting from cancer treatments is also available (Quinn et al 2016, Kumar et al 2018). These evidence-based recommendations should inform any local mouth care protocols and be accessed regularly to ensure local practice is up to date.

A person-centred approach should always be used when undertaking an oral assessment and mouth care. It is essential that nurses use a reliable and valid tool for oral assessments, such as the BOHSE, the Revised Oral Assessment Guide or the Oral Health Assessment Tool (Australian Institute of Health and Welfare 2009, NICE 2016). These tools can be adapted for local use; however, it is important to be aware that such adaptations may affect a tool’s reliability, so they should be approached with caution or avoided if possible.

The use of foam sticks to remove oral debris and dental plaque has been shown to be ineffective (Binks et al 2017, Argenio-Haines et al 2020), with a UK national alert identifying a choking risk incurred by detachment of the foam head on these sticks (Medicines and Healthcare products Regulatory Agency 2012).

Mouthwash solutions such as chlorhexidine are effective as an antibacterial and anti-plaque agent (Argenio-Haines et al 2020). However, the use of these mouthwashes should generally not replace the use of a toothbrush, unless brushing is not possible.

Mouth care considerations in various settings

It has been identified that there are often specific challenges in achieving effective mouth care in certain care environments and situations. For example, the Care Quality Commission (2019) and Doshi et al (2021) reviewed mouth care in nursing homes and noted various barriers to effective care, such as: suboptimal access to dental services; the low number of care homes with a policy for promoting and protecting people’s oral health; and staff who had not received specific training in oral healthcare. In addition, where patients have cognitive impairment due to conditions such as dementia, they may exhibit care-resistant behaviour. Doshi et al (2021) suggested various practical interventions for nurses attempting to provide mouth care in this situation, including: developing a mouth care routine; delivering mouth care in a calm manner and in short episodes; mirroring techniques with the patient to demonstrate the procedure; and the use of distraction techniques such as music or singing.

Another consideration for nurses is the oral care of patients at the end of life, when secretions can accumulate in the mouth or the mouth can become severely dry. A small-headed toothbrush dipped in water can be used to hydrate the mouth in this situation.

The charity Marie Curie (2021) provides useful mouth care advice that nurses can incorporate into their practice when caring for patients at the end of life, including: encouraging the patient to take small frequent drinks; undertaking mouth care when the patient is semi-upright to reduce the risk of choking; and ensuring fluid does not collect in the patient’s mouth, again to reduce the risk of choking.

In the intensive care unit environment, mouth care for patients who are receiving mechanical ventilation is particularly challenging. This is in part due to the presence of an endotracheal tube, which can obscure the mouth, hinder oral hygiene procedures and exert pressure on soft tissues. Welch (2017) detailed some circumstances that can lead to suboptimal oral hygiene in this patient group, including reduced saliva production due to a lack of oral stimulus when eating, reduced or absent oral fluid intake, and compromised immunity potentially leading to oral infections. Another risk in patients who are receiving mechanical ventilation is pneumonia resulting from the aspiration of oropharyngeal secretions that have been colonised by pathogenic bacteria and not swallowed or rinsed away during fluid intake or oral hygiene procedures. Pneumonia is also a factor in nursing homes, where residents may have limited mobility, suboptimal lung expansion capacity and compromised cough strength (Son et al 2017).

In patients who are receiving mechanical ventilation, regular mouth care will include the use of a Yankauer suction catheter to remove accumulated oral secretions, brushing with a non-foaming toothpaste and frequent moistening of the mucosa with swabs (Welch 2017). Local policy may also include the application of chlorhexidine dental gel over the patient’s teeth and gums after the use of toothpaste and brushing; evidence has suggested this technique may reduce the incidence of ventilator-associated pneumonia (Li et al 2015).

Psychological support

Severe oral conditions can have adverse psychological effects on a patient, such as the development of anxiety or depression (Barkokebas et al 2015, Myatt 2021). Therefore, it is important for nurses to take a compassionate approach and keep in mind that referrals for psychological support may be required. Myatt (2021) asserted that nurses can support patients by using reliable and valid assessment tools such as the Hospital Anxiety and Depression Scale (Zigmond and Snaith 1983), to guide referral to appropriate psychological services.

References

  1. Argenio-Haines S, Rezende H, Llewelyn R (2020) Patient comfort and supporting personal hygiene. In Lister S, Hofland J, Grafton H (Eds) The Royal Marsden Manual of Clinical Nursing Procedures. Tenth edition. Wiley Blackwell, Oxford, 394-444.
  2. Australian Institute of Health and Welfare (2009) Caring for Oral Health in Australian Residential Care. http://www.adelaide.edu.au/arcpoh/downloads/publications/reports/dental-statistics-research-series/2009-2010-residential-care.pdf (Last accessed: 19 August 2021.)
  3. Barkokebas A, Silva IH, de Andrade SC et al (2015) Impact of oral mucositis on oral-health-related quality of life of patients diagnosed with cancer. Journal of Oral Pathology and Medicine. 44, 9, 746-751. doi: 10.1111/jop.12282
  4. Binks C, Doshi M, Mann J (2017) Standardising the delivery of oral health care practice in hospitals. Nursing Times. 113, 11, 18-21.
  5. Care Quality Commission (2019) Smiling Matters: Oral Health Care in Care Homes. http://www.cqc.org.uk/sites/default/files/20190624_smiling_matters_full_report.pdf (Last accessed: 19 August 2021.)
  6. Doshi M, Lee L, Keddie M (2021) Effective mouth care for older people living in nursing homes. Nursing Older People. doi: 10.7748/nop.2021.e1320
  7. Health Education England (2019a) Mini Mouth Care Matters. A Guide for Hospital Healthcare Professionals. http://mouthcarematters.hee.nhs.uk/wp-content/uploads/sites/6/2020/01/MINI-MCM-GUIDE-2019-final.pdf (Last accessed: 19 August 2021.)
  8. Health Education England (2019b) Mouth Care Matters: Toolkit for Improving Mouth Care in Hospitals. http://mouthcarematters.hee.nhs.uk/wp-content/uploads/sites/6/2019/12/MCM-toolkit-2019-V9.pdf (Last accessed: 19 August 2021.)
  9. Kumar N, Brooke A, Burke M et al (2018) The Oral Management of Oncology Patients Requiring Radiotherapy, Chemotherapy and/or Bone Marrow Transplantation: Clinical Guidelines. http://www.bsdh.org/index.php/component/edocman/?task=document.viewdoc&id=460&Itemid= (Last accessed: 19 August 2021.)
  10. Li L, Ai Z, Li L et al (2015) Can routine oral care with antiseptics prevent ventilator-associated pneumonia in patients receiving mechanical ventilation? An update meta-analysis from 17 randomized controlled trials. International Journal of Clinical and Experimental Medicine. 8, 2, 1645-1657.
  11. Medicines and Healthcare products Regulatory Agency (2012) Medical Device Alert. Oral Swabs with a Foam Head. Ref: MDA/2012/020. http://assets.publishing.service.gov.uk/media/5485ac0440f0b60241000271/con149702.pdf (Last accessed: 19 August 2021.)
  12. Myatt R (2021) Understanding oral mucositis and the principles of effective mouth care. Nursing Standard. doi: 10.7748/ns.2021.e11717
  13. National Institute for Health and Care Excellence ( 2016) Oral Health for Adults in Care Homes. NICE guideline No. 48. NICE, London.
  14. Nursing and Midwifery Council (2018) The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates. NMC, London.
  15. Public Health England (2017) Delivering Better Oral Health: An Evidence-Based Toolkit for Prevention. Third edition. PHE, London.
  16. Quinn BG, Botti S, Kurstjens M et al (2016) European Oral Care in Cancer Group: Oral Care Guidance and Support. First Edition. http://www.wsbhospices.co.uk/wp-content/uploads/2017/12/EOCC-Guidelines-online-version-v8.pdf (Last accessed: 19 August 2021.)
  17. Quinn BG, Campbell F, Fulman L et al (2020) Oral care of patients in the cancer setting. Cancer Nursing Practice. doi: 10.7748/cnp.2020.e1706
  18. Son YG, Shin J, Ryu HG (2017) Pneumonitis and pneumonia after aspiration. Journal of Dental Anesthesia and Pain Medicine. 17, 1, 1-12. doi: 10.17245/jdapm.2017.17.1.1
  19. Van Dyke TE, van Winkelhoff AJ (2013) Infection and inflammatory mechanisms. Journal of Clinical Periodontology. 40, Suppl 14, S1-S7. doi: 10.1111/jcpe.12088
  20. Welch J (2017) The patient within the critical care environment. In Adam S, Osborne S, Welch J (Eds) Critical Care Nursing: Science and Practice. Third edition. Oxford University Press, Oxford, 40-81.
  21. World Health Organization Regional Office for Europe (2021) Oral Health. http://www.euro.who.int/en/health-topics/disease-prevention/oral-health (Last accessed: 19 August 2021.)
  22. Zigmond AS, Snaith RP (1983) The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica. 67, 6, 361-370. doi: 10.1111/j.1600-0447.1983.tb09716.x

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