Effects of oral care solutions on mucous membrane integrity and bacterial colonization

RESEARCH

doi: 10.1111/nicc.12057

Effects of oral care solutionson mucous membrane integrityand bacterial colonizationDilek Ozden, Gulengun Turk, Cevdet Duger, Elem K Guler, Fatma Tok and Zuhal Gulsoy

ABSTRACTAim: This research was conducted with the aim of determining the influence of three different oral care solutions on oral mucous membraneintegrity in critically ill patients.Background: Oral care is a basic part of nursing care in intensive care units.Design: A randomized controlled trial was conducted.Method: A total of 60 patients (20 patients in each group) comprised the study sample of the research. Patients were randomly allocated tothree groups. Patients in groups 1, 2 and 3 were administered mouth care three times a day using 5% sodium bicarbonate, 0·2% chlorhexidineand saline solution, respectively. Data were collected by means of a ‘Descriptive characteristics form’ and an ‘oral assessment tool’.Results: Mean scores of oral assessment tool increased according to days in all groups, however, this increase was found to be statisticallyinsignificant (p>0·05). Mean scores of the patients in saline solution group were seen to be lower than those of the other groups. Wheninter-group comparison of days was done, the difference between oral assessment scores was found to be statistically significant (p=0·000).Conclusion: It was found that there was no difference between patient groups receiving saline solution, sodium bicarbonate and 0·2%chlorhexidine for mouth care in terms of oral mucous membrane integrity; oral mucosa of all patients was found to be mildly dysfunctioning.Relevance to clinical practice: It is thought that standardized protocols for oral hygiene developed in the light of the findings ofrandomized controlled trials may improve the oral health in critically ill patients.

Key words: Intensive care unit • Mechanical ventilation • Oral care • Oral care solutions

INTRODUCTIONOral care is a basic component of nursing care carriedout in order to provide cleanliness and moisture,maintain the integrity of oral mucosa, remove debrisand plaque and prevent other oral problems (Cutlerand Davis, 2005; Costello and Coyne, 2008; Hsu et al.,2010; Yeung and Chui, 2010; Adib-Hajbaghery and

Authors: D Ozden, PhD, RN, Assistant Professor, Fundamentals ofNursing Department, Cumhuriyet University, Health Sciences Faculty, Sivas,Turkey; G Turk, PhD, RN, Assisstant Professor, Fundamentals of NursingDepartment, Adnan Menderes University, School of Health, Aydin, Turkey;C Duger, MD, Assisstant Professor, Cumhuriyet University Medicine Faculty,Sivas, Turkey; EK Guler, MSc, RN, Research Assistant, Fundamentals ofNursing Department, Ege University School of Nursing, Izmir, Turkey;F Tok, MSc, RN, Research Assistant, Fundamentals of Nursing Department,Cumhuriyet University, Health Sciences Faculty, Sivas, Turkey; Z Gulsoy,RN, Cumhuriyet University, The Medicine Faculty Hospital, Sivas, TurkeyAddress for correspondence: G Turk, PhD, RN, Fundamentals ofNursing Department, Adnan Menderes University, School of Health, 09100Aydin, TurkeyE-mail: [email protected]

Azizi-Fini, 2011; Lam Soh et al., 2011; Snyders et al.,2011).

BACKGROUNDPatients hospitalized in intensive care units (ICU)have a greater risk of developing oral problems ascompared to other patients. Factors for this increasedrisk include sedative and muscle relaxant use, patient’sstate of consciousness, high concentration O2 therapy,endotracheal tube cuff pressure, inadequate nutrition,impaired immune system, reduced saliva productionand the general inability to carry out personal oralcare (Stonecypher, 2010; Snyders et al., 2011). Inaddition, mucociliary clearance is hindered due tothe suppression of natural defence mechanisms suchas cough and retching reflexes and ventilator deviceswhich manipulate the heat and moisture of inhaledair (Safdar et al., 2005). While a partially open mouthin intubated patients leads to xerostomia (dry oralmucosa), activation of the sympathetic nervous systemleads to worsening of the dryness by reducing salivaproduction. Protecting the oral mucosa delays the

78 © 2013 British Association of Critical Care Nurses • Vol 19 No 2

Oral care in patients connected to mechanical ventilator

accumulation, colonization and microaspiration ofpathogen bacteria such as Pseudomonas aeruginosa,Acinetobacter baumannii and Staphylococcus aureus in theoral cavity and oropharynx (Abidia, 2007; Stonecypher,2010; Snyders et al., 2011). This condition increases thesusceptibility to nosocomial infections in ICU patientsconnected to a mechanical ventilator (Fourrier et al.,2005; Safdar et al., 2005; Bopp et al., 2006; Scannapiecoet al., 2009; Jones et al., 2010; Stonecypher, 2010).

The most common oral complications seen inICU patients include xerostomia which can progressto nosocomial pneumonia and ventilator-associatedpneumonia (VAP). Nosocomial infections are amongthe leading causes of infection-related death in hospi-talized patients. VAP is the second leading nosocomialinfection seen in patients receiving mechanical ven-tilator support (Harris and Miller, 2000; Yates, 2003;Fourrier et al., 2005; Safdar et al., 2005; Fields, 2008;Stonecypher, 2010; Snyders et al., 2011). The risk ofVAP development varies between 10% and 20% withinthe first 48 h following intubation (Fourrier et al., 2005;Stonecypher, 2010; Snyders et al., 2011).

In ICU patients, if unprotected, oral complicationslike xerostomia and VAP can lead to serious problems.Changes in the oral mucosal membrane result in VAPand increased antibiotic use which increases the riskof infection with other microorganisms. This conditionprolongs the duration of ventilation and hospitaliza-tion. Prolonged treatments and hospitalization alsoincrease health care costs. In addition, the risk of deathis doubled in patients who develop VAP (Stonecypher,2010; Snyders et al., 2011).

Several studies investigating the relationshipbetween oropharyngeal colonization and the devel-opment of VAP (Fourrier et al., 1998; Harris and Miller,2000; Grap and Munro, 2003; Yates, 2003; Jones et al.,2010) have highlighted this issue, which has led tothe development of methods to prevent oral compli-cations. To prevent oral complications like VAP andto preserve the integrity of oral tissues, sterility of thelower respiratory tract must be maintained.

In literature, certain methods have been reportedto prevent oral problems in ICU patients. Theseinclude oral care, disinfection of the related hospitalarea, sterilization of the devices used in the ICU,administration of the pneumococcus vaccine andeducating health care professionals on personalhygiene (hand washing) in order to prevent furthercross contamination. Other effective measures includethe reduction of intubation time, continual aspirationof subglottic secretions and positioning patients inSemi-Fowler position because it is found to reduce theincidence of VAP. Semi-Fowler position is the elevationof the head of the patient’s bed to 30–45◦ (Yates, 2003;

Stonecypher, 2010; Snyders et al., 2011; Goss et al.,2011).

Studies have reported that oral care, which shouldbegin with a comprehensive mouth evaluation,includes the brushing of teeth and the use of antisepticmouth wash solution and moisturizers. Antisepticsolutions used for oral care vary from study to study.Chlorhexidine is an important disinfectant used for thetreatment of gingivitis in patients receiving mechanicalventilation and as a dental plaque inhibitor (Fourrieret al., 2005; Scannapieco et al., 2009; Snyders et al.,2011). Studies have shown the incidence of VAP andother bacterial infections to decrease with the topicaluse of chlorhexidine and brushing teeth. (Tablanet al., 2004; Craven, 2006). Hydrogen peroxide andsodium bicarbonate are effective for the removal ofdebris; however, they can lead to superficial burnsif not appropriately diluted. Saline solutions do notcause any injuries to the oral mucous membrane.Oral care remains to be viewed as a minor problemwhen compared to the procedures of preserving vitalfunctions. Nurses have reported that they do not havethe time for patient’s oral care because of the highpatient-to-nurse ratio and the high degree of carerequired for ICU patients. (DeKeyser Ganz et al., 2009;Yeung and Chui, 2010; Lam Soh et al., 2011; Turket al., 2012). These conditions impede the prevention oforal problems in ICU patients. Many researchers havereported that oral hygiene protocols and antimicrobialproducts are effective in preventing oral complicationsin the ICU (Fourrier et al., 1998; Tablan et al., 2004;Didilescu et al., 2005; Fourrier et al., 2005; Scannapiecoet al., 2009; Prendergest et al., 2012). In the study byOzcaka et al. (2012) conducted in ICU patients, theyfound the development of VAP to be significantlyless frequent in patients where chlorhexidine wasused in oral care as compared with patients receivingsaline solution. In the study by Berry et al. (2011), theincidence of VAP in patients using saline solution,chlorhexidine and bicarbonate were found to be 1,0·2 and 5%, respectively. In another study conductedon mechanically ventilated patients by Munro et al.(2009), clinical pulmonary infection scores were higherin those who only had their teeth brushed as comparedwith patients who used 0·12% chlorhexidine. Onreviewing various studies, there does not seem tobe evidence to support the use of oral solutions.Therefore, there remains the need for evidence-basedstudies on cost effective and practical protocols. Studiesdetermining the most effective oral solution for thispatient population are limited. In addition, no studywas encountered that investigated the influence ofthese solutions on oral mucous membrane integrity.Therefore, this study was conducted with the aim of

© 2013 British Association of Critical Care Nurses 79


determining the influence of three different oral caresolutions on mucous membrane integrity and bacterialcolonization in patients connected to mechanicalventilators.

RESEARCH QUESTIONS

• Is there any relationship between patient charac-teristics (demographic and clinical variables) andoral assessment tool scores?

• Is there any difference between the three groups(chlorhexidine 0·2% group, 0·5% sodium bicar-bonate group and normal saline group) in termsof oral assessment tool scores?

• Is there any relationship between patient charac-teristics (demographic and clinical variables) andoral microbial cultures?

• Is there any difference between three groups(chlorhexidine 0·2% group, 0·5% sodium bicar-bonate group and normal saline group) in termsof oral microbial cultures?

• Is there any relationship between oral microbialcultures and oral assessment tool scores?

METHODSDesignThis is a randomized controlled experimental study.The research was conducted in the ICU of theAnaesthesia and Reanimation ward, at a UniversityResearch and Training Hospital between June 2011and June 2012. This ICU has 25 beds and is located ina clinic which treats an average of 400 patients yearly.

SampleThis study population included patients older than18 years hospitalized in the ICU of the Anaesthesiologyand Reanimation department, connected to mechanicalventilators and who were on the first day ofintubation. Exclusion criteria for the patients wereas follows: previous intubation, lack of natural teeth,surgery involving the oral cavity, thrombocytopenia,leukopenia, stomatitis, oral apthous (aphtha) lesions,candidiasis and gingivitis. Patients were followed upfor 4 days.

The study population was determined using NCSS(Number Cruncher Statistical System)-Statistical andPower Analysis Software-PASS (Power Analysis andSample Size) programmes according to the poweranalysis and sample size calculation formula. Samplesize was determined as a total of 60 patients with20 in each based on the values of α = 0·01, B = 0·10,power = 0·90, p = 0·9023.

Instruments and data collectionData was collected from the records of the patientdemographics form, patient follow-up form, oralassessment tool and microbiological follow-up form.

The demographic and clinical features of the patientswere obtained from patient hospital records, andentered unto a descriptive form prepared by theresearchers that was based on literature and fromthe relatives of the patients. Oral assessment toolscores, vital findings possibly affecting oral mucosa,parameters such as leukocyte and thrombocyte values,PaO2 (partial oxygen pressure) and FiO2 were followedfor 4 days and recorded on oral assessment follow-upforms.

The type and number of microorganisms that werefound in the oral cavity on the first and fourth days ofintubation were recorded on microbiologic follow-upforms.

The three different oral care solutions that were pre-pared and used abiding by the guidelines in literaturewere 5% sodium bicarbonate, 0·2% chlorhexidine and0·9% NaCl.

The oral assessment tool developed by Eilers et al.(1988) was used in this study. The reliability of the toolwas found to be 0·91.

The oral assessment tool studies five parts; the lips,mucosa, tongue, teeth and saliva. Each part of thescale scores between 1 and 4 and the total scorevaries between 4 and 20. A total score below 5 fororal mucosa was accepted as ‘normal’, between 6and 10 as ‘mild dysfunction’, between 11 and 15 as‘moderate dysfunction’ and between 16 and 20 as‘severe dysfunction’.

All nurses working in the clinical unit were informedabout the purpose of the study and prior to theinitiation of the study, a 2-h training session wasgiven on the procedure. The training of nurses (n = 25)included oral care protocols with theoretical andpractical information. Once the protocol had been putinto action, data was collected. The nurse in chargerandomized the patients. The first patient receivedoral care using 5% sodium bicarbonate, the secondreceived 0·2% chlorhexidine, the third received 0·9%NaCl (Figure 1). Coloured stripes indicating the formof oral care given were placed on the beds and followedby the nurses.

The oral mucous membrane of patients wasevaluated using an oral assessment tool every morningfor 4 days by a researcher blinded to the coloured strips.Cultures were obtained from the oral mucosa on thefirst and fourth days of the study. To evaluate bacterialcolonization, the number and type of microorganismwas investigated.

80 © 2013 British Association of Critical Care Nurses


First Group (n=20) Allocated to 0.5% sodium bicarbonate intervention 3

times a day

Second Group (n=20) Allocated to saline solution

intervention 3 times a day

Third Group (n=20) Allocated to 0·2%

clorhexidine intervention 3 times a day

Randomized N=60

Figure 1 Randomization of the patients.

Ethical considerationsWritten approval was obtained from the Ethics Com-mittee of the University Faculty of Medicine (number2011/060) and the institution where the study wasconducted. Approval was obtained from the involvedhospital prior to the study. The informed consent ofpatients who were intubated or unconsciousness wasobtained from first degree relatives. Written formsexplaining the purpose and method of the study weregiven to the patients’ relatives. They were ensuredthat their anonymity would be guaranteed, that theirparticipation or withdrawal from the study would beof their own free will and that any refusal to participatewould not result in any negative consequences.

Data analysisThe data collected in the study was evaluated usingthe SPSS (Statistical Package for Social Science)for Windows 14 statistical package program. Dataincluding descriptive features such as demographicand clinical features, parameters that may be effectiveon the oral mucosa, oral assessment tool scores andfeatures of the microorganism detected in the oralmucosa were given a number and percent.

The Friedman, Wilcoxon signed rank test was usedto determine the difference between oral assessmenttool scores on the first and fourth days and One-WayANOVA was used for the difference between groups.For significance test between pairs, Mann-Whitney Utest and Kruskal-Wallis tests were used to compare thedifference between oral assessment tool scores on thefirst and fourth day according to certain features of theoral care solutions and health status. A p level of <0·05was accepted as statistically significant.

RESULTSDescriptive features of the patientsA total of 60 patients were included in this study. Thepatients were divided into three groups of 20 patients

each (Figure 1). Of the patients, 61·6% were 66 yearsor older, 56·6% were male, 70·0% were married, 46·6%were elementary school graduates and 91·7% wereunemployed; 41·7% of the patients who received oralcare had respiratory insufficiency and 83·3% were non-smokers.

Of the patients, 80% were determined to have achronic disease, all were aspirated with the closedsystem aspiration method, 80% received enteralnutrition, 20% received parenteral nutrition and 60%were using antibiotics.

The distribution of average oral assessment toolscores according to oral care application day is shownin Table 1. The oral mucosa of all patients was foundto have a mild degree of dysfunction according tothe oral assessment tool scores on the first and fourthdays. The average scores increased with each day inall the groups, however, this increase was found tobe statistically insignificant (p > 0·05). Oral assessmenttool scores on the last day were found not to displayany difference among the three groups (p > 0·05). Thescores of patients who received saline solution fororal care were found to be lower than those of theother groups. When the mean scores on the first andfourth days were compared, it was observed that whilethe sodium bicarbonate and chlorhexidine groups hadsimilar scores, these scores were lower in the salinegroup.

When the days were compared to each other aspairs, the difference between the oral assessmentscores of all three groups was found to be statisticallysignificant (p = 0·000). In this paired comparison, theonly group to show differences in all the dayswas the chlorhexidine group (p < 0·05). While astatistically significant difference was found whenmean oral assessment tool scores of all three groupswere compared according to the first and the lastday, this difference was determined to be the mostsignificant in the sodium bicarbonate group (p = 0·000)(Table 2).



Table 1 Distribution of mean oral assessment tool scores according to oral care application days

Mouth care solutions

5% Sodium bicarbonate (n= 20) 0·2% Chlorhexidine (n= 20) Saline (n= 20) Statistical assessment∗

Days ±SS ±SS ±SS F p

Day 1 7·65± 2·03 8·00± 1·89 7·40± 2·08 0·451 0·639Day 2 8·95± 1·43 8·70± 1·97 8·55± 1·95 0·250 0·780Day 3 9·85± 1·72 10·00± 2·29 9·10± 2·02 1·131 0·330Day 4 9·80± 1·73 10·35± 2·62 9·25± 1·94 1·329 0·273

∗One-way ANOVA test.

Table 2 Distribution of the difference between mean oral assessment scores according to oral care solutions in all days

Days

Oral care solutions Z∗ p 1–2 1–3 days 1–4 days 2–3 days 2–4 days 3–4 days X2 p∗∗

%5 Sodium bicarbonate Z −3·225 −3·897 −3·874 −3·211 −2·675 −0·108 45·312 0·000p 0·001 0·000 0·000 0·001 0·007 0·914

Saline Z −3·108 −3·138 −3·178 −1·442 −1·608 −1·000 20·574 0·000p 0·002 0·002 0·001 0·149 0·108 0·317

%0·2 Chlorhexidine Z −2·334 −3·471 −3·440 −2·750 −3·036 −2·111 29·799 0·000p 0·020 0·001 0·001 0·006 0·002 0·035

∗Friedman test.∗∗Wilcoxon Signed Rank test.

A total of 21 different microorganisms were observedin the cultures taken on day 1 and day 4 (Table 3).While the presence of the microorganisms S. aureus,Alpha haemolytic streptococcus, Neisseria gonorrhoeae,Candida albicans, Enterococcus faecalis and Enterococcusfaecium decreased in the sodium bicarbonate group, C.albicans and Alpha haemolytic streptococcus decreased inthe saline group and Klebsiella pneumoniae, C. albicansand Acinetobacter baumannii decreased in the chlorhexi-dine group. In addition, C. albicans presence decreasedand K. pneumoniae increased in all groups. While P.aeruginosa stayed as a constant in the saline group, itincreased in the sodium bicarbonate and chlorhexidinegroups, S. aureus increased in the saline and chlorhex-idine groups and decreased in the sodium bicarbonategroup. While A. baumannii presence stayed constantin the sodium bicarbonate group, it increased in thesaline group and decreased in the chlorhexidine group.

Relationship between descriptivecharacteristics and oral assessment tool scoresWhile a statistically significant difference was notfound between the patients’ smoking status andoral assessment tool scores on the first and fourthdays (p > 0·05), a significant difference was foundbetween groups in turns of age, gender, presence ofa chronic disease and antibiotic use (p < 0·05). Whileoral assessment tool scores of the younger patients

in the sodium bicarbonate group did not show adifference between the first and fourth days (p > 0·05),they did show a difference in the elderly (p < 0·05).On the last day, the mean oral assessment tool scoresof the patients fed enterally were found to be lower(9·28 ± 1·85) as compared with those fed parenterally(12·83 ± 2·56) in the chlorhexidine group (p = 0·005).These last day scores were found to be higher inthe enterally fed patients in the bicarbonate andsaline groups. The mean oral assessment tool scoresin patients with normal or high leukocyte counts inthe bicarbonate and chlorhexidine groups displayeddifferences on the first and the last day (p < 0·05). Thisdifference was not seen in patients in the saline group,whose leukocyte counts remained normal (p > 0·05).

DISCUSSIONOral care is a basic nursing procedure in the ICU.Assessment of the oral cavity using standardizedmethods is important for the planning and evaluatingof oral care in ICU patients (Berry et al., 2011). Astandard guideline for oral care is not used in ICUsand therefore the solutions and devices used for thispurpose vary. In this study, the effects of three differentoral care procedures on oral mucous membraneintegrity and bacterial colonization were investigatedin patients connected to mechanical ventilators.



Table 3 Distribution of microorganism types that grew on 1 and 4 days according to oral care solutions

Mouth care solutions

5% Sodium bicarbonate Saline 0·2% Chlorhexidine

Microorganism type 1 day (n) 4 day (n) 1 day (n) 4 day (n) 1 day (n) 4 day (n)

Pseudomonas aeruginosa 0 3 1 1 0 2Staphylococcus aureus 3 2 3 4 4 6Acinobacter baumannii 0 0 1 2 4 2Escherichia coli 3 5 4 5 5 4Alpha haemolytic streptococcus 17 13 15 13 9 11Neisseria gonorrhoeae 10 7 13 6 7 8Candida albicans 3 2 4 3 4 3Enterococcus faecalis 1 0 0 1 0 0Klebsiella pneumoniae 0 1 1 2 0 5Enterococcus faecium 2 1 0 0 0 0Klebsiella oxytoca 2 0 0 0 0 1

Comparison of oral assessment tool scoresbetween groupsAccording to our results, oral assessment tool scoreson the first and the last day were indicative of milddysfunction. When general clinical conditions (con-sciousness, multiple medical diagnoses, mechanicalventilation treatments, medications etc.) and factorsarising from the ICU environment are taken into con-sideration, this oral mucosal condition is expected.Although oral assessment tool scores tended to increasewithin days, this was not found to be statistically sig-nificant (p > 0·05) (Table 1). The statistical significanceof this difference varies if the sample size is larger andthe follow-up period is longer. In assessments made forthe last day, although oral assessment tool scores donot differ significantly in the three groups, the meanscores were found to be lower on all days in salinesolution group. This may be due to the fact that in thesaline group the oral assessment tool score was loweron day 1 and the positive effects that saline has on oralmucous membrane integrity.

The mean scores showed significant differencein paired comparisons in all three groups, sodiumbicarbonate led to the greatest difference in the firstand the last day scores. These changes in scores maybe explained by the effects of oral care solutions on theoral cavity.

The difference between scores of the three groupswas found to be statistically insignificant on the lastday of the study. This difference could be significantif the sample size was greater. In a review by Abidia(2007) and Snyders et al. (2011), the use of chlorhexidinewas recommended even in varying concentrations(0·12% and 2%). The recommendation of varyingconcentrations of chlorhexidine may be due to the

differences in oral conditions or problems other thansample groups. In our study, a 0·2% concentrationof chlorhexidine was found to be sufficient becauseonly the effects of oral solutions on the oral mucousmembrane were investigated. Chlorhexidine was notfound to be more effective than the other two solutions.

Types of microorganisms according to oral caresolutionsIt has been reported that patients in the ICUare exposed to microorganisms causing nosocomialinfections 48–72 h after hospitalization. They are atrisk for nosocomial infections and VAP developmentbecause of the medical interventions, treatments andtheir existing diseases. The most common VAP agentsare A. baumannii and P. aeruginosa (Harris and Miller,2000; Aygun et al., 2004; Craven, 2006, Yuceer andDemir, 2009).

In our study, various microorganisms were found togrow in the cultures. When the microorganisms wereanalysed for their potential to cause oral complications,while P. aeruginosa remained as a constant presence inthe saline solution group, it was found to increasein the sodium bicarbonate and chlorhexidine groups.This may be related to the fact that saline solution hasno negative effects on mucous membrane integrity.S. aureus levels were seen to increase in the salinesolution and chlorhexidine groups and decrease in thesodium bicarbonate group. While A. baumannii levelsstayed constant in the sodium bicarbonate group, theyincreased in the saline group and decreased in thechlorhexidine group. When literature was analysed,it was observed that studies supported the effects ofchlorhexidine on the prevention of VAP. (Munro et al.,2009; Browne et al., 2011; Soh et al., 2012). In our study,



we found that A. baumannii, one of the most importantmicroorganisms for VAP development, showed adecrease only in the chlorhexidine group. It wasinteresting to observe an increase in S. aureus numbersin the chlorhexidine group. This microorganism causesVAP and in various studies has been reported toreduce in number with the use of chlorhexidine (Boppet al., 2006; Scannapieco et al., 2009; Cabov et al.,2010, Snyders et al., 2011). This inconsistency wasthought to be related to the short follow-up periodand possible existence of other infections. In thestudy by Ozcaka et al. (2012) comparing the effectsof 0·2% chlorhexidine and saline on VAP prevention,chlorhexidine was found to be more effective in theprevention of VAP (p = 0·003). In addition, in the samestudy, A. baumannii was found to be the most commonpathogen in 34 patients who developed VAP. Ourresults were inconsistent with those of Ozcaka et al.(2012) because we did not consider VAP as an outcomein our study rather we evaluated oral mucosa andtype and number of cultured microorganisms. We didnot assess the presence of VAP in our patients. In thestudy by Cabov et al. (2010), the ratio of pathogenmicroorganisms was found to be significantly lowerin their 0·2% chlorhexidine group compared with thebicarbonate and saline groups (p = 0·002).

The relationship between descriptivecharacteristics and oral assessment tool scoresA statistically significant difference was not foundbetween certain descriptive characteristics such assmoking status, leukocyte counts and oral assess-ment tool scores on the first and fourth days(p > 0·05). In the 0·2% chlorhexidine group, the meanscores of the patients who required enteral nutri-tion (9·28 ± 1·85) were found to be lower than inthose who required parenteral nutrition (12·83 ± 2·56)(p = 0·005).

While oral assessment tool scores of the youngerpatients in the sodium bicarbonate group did not showany difference on days 1 and 4, differences were seenin the older patients. This condition is probably dueto the insufficiency of the protective mechanisms oforal mucosa stability caused by physiologic changessuch as decreased salivation in the elderly and factorsarising from the ICU environment.

First and last day scores were found to be significantwith regard to gender, presence of chronic diseasesand antibiotic use. In a study by Cabov et al. (2010)conducted using bicarbonate, saline solution and 0·2%chlorhexidine, a significant difference was not foundbetween group in turns of age, gender, CAO score,plaque score, SASP2, MV and related factors (Cabovet al., 2010). In another study by Prendergest et al.,

2012 no difference was found between groups interms of age, gender, smoking, medical diagnosis andGCS score (Prendergest et al., 2012). Our results differfrom these studies. The differences may be explainedby varying characteristics and the size of the studysample.

On the last day of the study, the oral assessmenttool scores were found to be lower in the enterallyfed patients (9·28 ± 1·85) than in the parenterallyfed patients (12·83 ± 2·56) in the chlorhexidine group(p = 0·005). In the bicarbonate and saline groupsthese scores were higher on the last day than thefirst day in the enterally fed patients. In literature,it has been reported that parenteral nutrition hasmore disadvantages due to severe complications thatmay arise as compared to enteral nutrition (Cherry-Bukowiec, 2013; Williams et al., 2013). In our study,we also found that the oral mucosa of patients whoreceived parenteral nutrition in the chlorhexidinegroup was in poorer condition than the ones whoreceived enteral nutrition. This is an expected conditionfor the last day since oral intake in ICU patients is poor.Although the mean scores of patients with normal tohigh leukocyte counts were different on the first and thelast days in the bicarbonate and chlorhexidine group(p < 0·05), there was no difference in mean scores inthe saline group where leukocyte counts were normal(p > 0·05). In literature, saline is reported to have noharmful effects on oral mucosa. The stability of the oralmucosa in the saline group is thought to be the causeof normal leukocyte counts on the first and the lastdays. The differing scores seen in the bicarbonate andchlorhexidine groups may be due not to the leukocytelevel but to the difference of the solutions.

LIMITATIONS OF THE STUDYIn this study, culture findings were restricted tomicroorganism identification. The specific numbers ofmicroorganisms were not evaluated due to the requiredcost and time. This was accepted as the limitation ofour study.

The strengths of the studyIn literature, it has been reported that basic methodsfor oral care although present are not frequently usedand the importance of research-based protocols forpatient care has been emphasized. In our study, wefirst used an oral assessment tool ensuring reliabilityand validity before the oral solutions effectiveness wasevaluated and this was seen as the strength of thestudy.



CONCLUSIONSIn this study, the effects of three different oral careprotocols on oral mucous membrane integrity andbacterial colonization were investigated in patientsconnected to mechanical ventilators. Our study resultsfound that there were no differences between saline,0·2% chlorhexidine and bicarbonate groups in termsof oral mucous membrane integrity. The oral mucosaof all patients in all three groups was mildly affected.Various types of microorganisms were identified in thecultures taken from all the three groups, P. aeruginosawas found to remain constant in the saline group andincreased in the other groups. According to the resultsof this study, these three solutions may be used fororal care to maintain oral mucous membrane integrityin ICU patients connected to mechanical ventilators.Conducting this study with the same solutions on alarger patient group and evaluating the number ofmicroorganisms in the cultures can be recommended.

Relevance to clinical practiceIt is believed that standardized protocols for oralhygiene developed in the light of the findings ofrandomized controlled trials may improve the oralhealth in critically ill patients.

ACKNOWLEDGEMENTSWe thank all instructor physicians and clinicalnurses working in the Intensive Care Unit. Wewould also like to thank the ICU of the Anaes-thesiology and Reanimation Department. We alsothank all the patients who participated in thisstudy.

CONFLICT OF INTERESTSThere was no financial relationship or any other setof circumstances that might affect or might reasonablybe thought by others to affect, an author’s judgment,conduct or manuscript.

WHAT IS KNOWN ABOUT THIS TOPIC

• Patients connected to mechanical ventilators are under greater risk for oral problems compared with other patients.• Oral care is a basic part of nursing in critically ill patients, to prevent oral problems.

WHAT THIS PAPER ADDS

• This study provides information about the effects of different solutions on integrity of oral mucous membrane. In this sense, this study isthought to be a contribution to literature.

• Also we have demonstrated an example of an intensive care unit from Turkey.

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Documents

Effects of oral care solutions on mucous membrane integrity and bacterial colonization