Don't limit your search to oral and sinus causes . There are a gazillion conditions body wide that can cause bad breath. One possibility is respiratory acidosis which causes a distinctive acetone odor similar to nail polish remover. Diabetes can cause a more fruity acetone odor. If the cause does seem to be oral, it may be possible to get a home visit from a dentist to do a basic check and if there is need for dental work, it would be an opportunity to discuss how the work could be done in the office.
Although it may seem impossible to get anything else into their mouths for cleaning, sponge "lollipops" should never be used with these patients. If the sponge gets pulled off the stick when you are trying to get it out of his mouth, he could choke on it. They can do little to clean the mouth anyway.
A jaw screw is a last resort for getting into his mouth. If not positioned correctly -- between the back molars-- it can break other teeth. It can break weak molars or catch the insider of the cheek and grind it up as you screw it in.
Instead, create thick bite block pad to put between the molars using tongue depressors and medical bandage type adhesive tape. Stack several tongue depressors together and wrap adhesive tape thickly around one end (half way up the stick) in layers. Make sure that it is securely taped down so it won't slide off. When finished, the taped end needs to be ½ to 3/4 of an inch thick. The layered tongue depressors give it strength and the adhesive tape hold them together and pads it.
To do mouth care, you will have to "sneak up" on those hyper-reflexive jaws. You have to get the bite block in place before the jaw clamps down. Try doing it when the patient is relaxed, even snoozing or yawning. Valium might be helpful. (If spasticity is severe, this will be a job that you will have to do when the opportunity strikes, and not necessarily as part of his morning bath.) Quickly put taped end of the bite block to the back and side of his mouth between his molars. Do not turn it on edge, just put it in flat. *****DO NOT put it between the front teeth! ****** The jaw clamping reflex can be strong enough to break front teeth, especially if they are weak to start with. The molars are a flatter surface, much stronger and intended to withstand grinding pressure. The tape will give some padding to the sticks to protect the teeth, and putting the bite block in flat will spread the pressure out evenly over the teeth. If he does get it between his front teeth, just let go and wait for the muscles to relax. Pulling on it will only increase the pressure and keep the jaw tight longer.
With the bite block in place, his jaws will be held far enough apart for you to maneuver the tooth brush around surprisingly well. If you can't, get a smaller tooth brush or make the next bite block thicker. Doing this while the patient is sitting up or turned at least part way on his side and/or using a suction machine while allow you to use a little more water without choking him. Be careful with the round plastic "wand" of the suction equipment however. It does not make a good bite block at all! To get the bite block out, just let go and wait for the muscles to relax. Sometimes by the time you are done with a good brushing, the muscles are already relaxing.
Diane
ALS: From Both Sides
