Registered Nurses' Association of Ontario

Standardized, Valid and Reliable Oral Assessment Tools

  • Nursing oral health assessments should be completed on all clients as part of a routine, systematic assessment (e.g. oral health assessments should be completed on admission, during routine monitoring and documented on the client’s health record).
  • Oral health assessments and screening can be conducted by educated nurses and caregivers, as appropriate, to monitor oral health, to evaluate oral hygiene care interventions, to initiate dental visits when required and to assist with individual oral hygiene care planning.
  • When selecting a screening/assessment tool the type of facility, the client population and staff mix should be considered. Instruments to be used should be setting and client-specific.
  • The nursing oral health assessment should identify those clients at risk for development of oral problems such as stomatitis, mucositis and periodontal diseases.
  • The following tools are examples of oral health assessment tools, recognizing that these instruments are setting and client specific. The interpretation of the assessment results vary from tool to tool (based on unique scoring systems, etc.); however, the results should guide decisions regarding the development of an individualized care plan and evidence-based interventions.

 

Oral Assessment Tool

Population

Oral Assessment Guide (OAG)

For use in acute care settings, ICU, cancer centres, rehabilitation settings

Revised Oral Assessment Guide (ROAG)

Validated in three small studies of geriatric rehab clients

Brief Oral Health Status Examination (BOHSE)

Validated in long-term care and residential care settings.

 

Can be used with cognitively impaired clients

Oral Health Assessment Tool (OHAT)

• Also known as the Modified Brief Oral Health Status Examination

For use in long-term care or residential care settings, and can be used with cognitively impaired clients

The Holistic and Reliable Oral Assessment Tool (THROAT)

Developed and tested for use in elderly hospitalized patients in a single trial.

Mucosal Plaque Index (MPS)

Measures only mucosal and plaque indices

 

Designed to assess oral care in groups of elderly patients/clients

National Cancer Institute (NCI) Scale

NCI is most commonly used in clinical trials

 

Scale to assess oral mucositis

 

Widely validated and extensively used.

World Health Organization (WHO) Grading Scale

Measures anatomical, symptomatic and functional components of oral mucositis.

 

Combines both objective mucosal changes (redness and ulceration) with functional outcomes (ability to eat) to arrive at a score.

 

The WHO Grading Scale is very frequently used in oncology clinical practice

 

Clinical Management
Oral Health: Nursing Assessment and Intervention
Sample Tools