Mouth CareGuideline

Intensive Care/High Dependency Stream

ICU Education Collaborative Group

August 2011Reviewed November 2012

Why is Oral Health important in ICU??

• Poor oral health may increase the risks of serious complications in Critically Ill Patients.

– Ventilator associated pneumonia is a major source of morbidity and mortality in the ICU.

– During periods of critical illness mouth care is sometimes relegated to a lower priority and often forgotten.

• What are some of the barriers to proper oral care in ICU???• An intact oral mucosa, like our skin is an effective barrier to

microbes

Why is Oral Health important in ICU??

• Dental plaque provides a breeding ground for respiratory pathogens

• A extracellular matrix• 1mm3 of plaque contains about 100 million bacteria • A resistant layer microorganisms adheres tenaciously to

teeth surfaces.

• Potential association between pathogenic bacteria in the mouth with those identified in the lungs.

• Healthy vs. ICU intubated pt

Oropharynx Colonisation-Pneumonia Pathway

Pathogenesis of VAP

Exogenous microbes Endogenous microbes

What is the current rate of infection?

• Reported mortality rates for VAP range from 24% to 50% – potential higher figures in immunocompromised

patients or when multi-resistant organisms are involved.

– Cost of VAP in the US;• A rise in the cost of care to $ US 10,000 – 40,000 per

case.• With increased mechanical ventilation days & LOS • Difficult to study due to problems with diagnosis.

Consequences of Poor Oral Hygiene

1. Xerostomia 2. Gingivitis3. Mucositis4. Periodontitis5. Candidiasis6. Halitosis

1.

2.

3.4.

5.

Normal Oral Environment• Normal Oral Flora

– Predominately Gram – positive streptococci and dental micro-organisms.

• Functions of Saliva– Lubricates– Buffering Properties– Antimicrobial Properties

• Immunoglobulin A which obstructs microbial adherence• Lactoferrin which inhibits bacterial infection• Fibronectin which blocks pathogenic bacterial attachment to oral

mucous membranes

During Critically Illness• The oral flora shifts dramatically to aerobic Gram –

negative bacilli and staphylococcus aureus within 48hrs of admission.

• Why??• More vulnerable for being colonised with exogenous microbes from

the ICU environment .• Increased severity of illness and length of stay • Patients are on multiple medications causing salivary dysfunction and

xerostomia• Constant opened mouth leading to dry mucus membranes. • Accumulation of dental plaque• A reduction in salivary immune factors such a Immunoglobulin A (IgA)• Increased levels of proteases in their oral secretions causing a

– Depletion of fibronectin exposing tooth surfaces to the attachment of organisms, such as pseudomonas aeruginosa.

Dental Plaque & Biofilms

• If plaque is allowed to grow undisturbed

• Bacterial adherence due to depletion of fibronectin

• Colonisation of the mouth• Changes in oral flora• Micro aspiration of

subglottic secretions.• Increase risk of developing

VAP

What has already been implemented to reduce VAP to date?

Ventilator BUNDLESHead of bed elevation to 30

– 45 degreesDaily ‘sedation vacations’

and assessment of readiness to wean

Peptic ulcer prophylaxisDVT ProphylaxisOral care with Chlorhexidine

GuidelinesGeneral

– Ventilation minimisation• Closed in line suctioning• Weekly circuit changes

– Hand hygieneSpecific

– Prevention of aspiration• Subglottic suctioning• Deep pharyngeal suctioning

– Reduce colonization of oropharyngeal tract

– Prevent contamination of respiratory equipment

HNEAH Mouth Care Guideline

Our aim is;• Maintain mouth moisture • Provide adequate salivary

flow together with

• Control of plaque formation* Through• Mechanical cleansing with a

tooth brush• Chemical cleansing with

Chlorhexidine.

HNEAH Mouth Care Guideline

• The HNEAH Guideline utilizes ;• Comprehensive mouth care assessment• Mouth care intervention plan• Twice daily brushing teeth, gums and tongue using a

soft paediatric toothbrush• Application of 0.2% chlorhexidine gel• Stimulation of the oral mucosa 2 - 4 hourly with a foam

swab to promote salivary flow• Maintain lip moisturizing every 4 hours with white soft

paraffin.

Mouth Care Assessment Tool

Category Rating 1 2 3

Lips 1 2 3 Smooth and pink Dry, cracked or chapped Peeling, split, ulcerated or bleeding

Tongue 1 2 3 Pink, moist and papillae present

Coated or loss of papillae with shinny appearance with or

without redness

Blistered or cracked, heavy coating, thrush or ulcerated

Saliva 1 2 3 Watery Thick or ropy Absent

Mucous Membranes

1 2 3 Pink and moist Reddened or coated (increased whiteness) without

ulcerations

Ulcerations with or without bleeding

Gingiva 1 2 3 Pink and firm Oedematous with or without redness

Spontaneous bleeding or bleeding with pressure

Teeth or Dentures (or denture

bearing area)

1 2 3 Clean and no debris Plaque or debris in localised areas

(between the teeth)

Plaque or debris generalized along gum line or denture

bearing area

MCAT intervention plan

Score 6 – 8 No Oral Dysfunction

VentilatedBD tooth brushing with chlorhexidine

gel 2 -4th hourly mouth moisturising with

water or water soluble mouth moisturiser

Daily MCAT

Non ventilatedBD tooth brushing with toothpaste

4th hourly mouth moisturising with water or water soluble mouth

moisturiser

Daily MCAT

Score 9 – 12 Mild Oral Dysfunction

BD tooth brushing with chlorhexidine gel

2nd hourly mouth moisturising with Sodium Bicarbonate swabs

Daily MCAT

BD tooth brushing with toothpaste

2nd hourly mouth moisturising with Sodium Bicarbonate swabs

Daily MCAT

Score 13 – 18 Moderate to SevereOral Dysfunction

Consider medical review

(e.g. Ulcerated areas and thrush)

BD tooth brushing with chlorhexidine gel

2nd hourly mouth moisturising with Sodium Bicarbonate swabs

Daily MCAT

BD tooth brushing with toothpaste

2nd hourly mouth moisturising with Sodium Bicarbonate swabs

Daily MCAT

Note

Patients with mucositis require medical review. Chlorhexidine is replaced with Sodium Bicarbonate and bland rinses ( ie Cetylpyridium Chloride or 1.5% Hydrogen Peroxide).

For patients’ ventilated for greater than 14 days tooth brushing with Chlorhexidine gel should be reduced to once a day and replaced with tooth brushing with water or mouth moisteriser.

What is the Evidence say ???

Consensus – Based Clinical Guideline

Tooth brushing

• Dental plaque is a very thick biofilm and requires the mechanical action of cleaning with a toothbrush.– Mouthwashes alone will NOT eliminate dental plaque

formation.– Biofilm protects bacteria against chemical agents such as

chlorhexidine

• Foam swabs do not remove plaque• Pearson (2006) showed the elimination of dental

plaque was more effective using a toothbrush than foam swab.

Denture Care• NB: Remove partial or full dentures from a ventilated patient and do not reinsert until patient is

extubated • For non-ventilated patients remove dentures prior to daily assessment as per Oral Hygiene Care

HNELHD CP11_35

 • For all patients with dentures:

 • Clean the palate, teeth, gums and tongue with a soft toothbrush or mouth swab• Inspect oral cavity as per MCAT (irritated or broken areas may indicate a poor fitting denture)• If available use patient’s own denture tooth brush and toothpaste to clean dentures with warm water

over a basin – Use only moderate pressure to prevent scratches– Rinse dentures thoroughly

• Dentures should be stored, cleaned and labelled in a denture container filled with water to prevent dentures drying out, shrinking or changing shape. This water needs to be changed every 24hrs and the storage container cleaned regularly to prevent growth of microorganisms

• To remove stains and hardened deposits, add warm water and denture cleaner (patient to supply)• Clean toothbrush thoroughly and store in a clean container separate from other personal hygiene

products.

Chlorhexidine Gluconate (CHG)

• Is an antiplaque agent with potent antimicrobial activity

• CHG binds to oral surfaces and released over time

• Chemically active on tissues for up to 6 – 12 hrs• BUT depends on adherence to CLEAN oral surfaces• Mechanical cleansing with toothbrush is recommended

first.

Chlorhexidine What's The Evidence??

• The evidence for the BEST solution is varied.• Two meta-analysis (Chan & Pineda) looking at

CHG– reported that although CHG may reduce the incidence

of VAP, it doesn’t reduce the time on the ventilator or lower mortality rates.

• A study by DeRiso and colleagues(1996)– showed a reduced number of respiratory infections

by 69% after applying CHG in post op cardiothoracic patients.

Chlorhexidine Gluconate (CHG)

• A study by Tantipong and colleagues showed– That oral decontamination with a higher

concentration of 2% CHG is more effective in preventing VAP than with a lower concentration.

– 9.8% of patients developed irritation of the oral mucosa.

• Adverse effects• Discolouration of the teeth & tongue• Alterations in taste perception• Increase calculus formation

Sodium Bicarbonate

• Is an odour absorber & acid neutraliser• Dissolves mucus and loosen oral debris• Neutralises plaque acids and is a natural

buffer• Breaks up plaque & inhibits the attachment to

tooth surfaces.• Recommended for Mucositis

Moisturizers

• A moisturizer should be used on the lips and inside the mouth to prevent drying and cracking

• Petroleum – based moisturizers should be avoided because they cause inflammation if open wounds are present

• Water – based moisturizers are preferred as such products are easily absorbed by the skin and provide additional hydration.

In Summary– Comprehensive mouth care

assessment with MCAT intervention plan

– Twice daily brushing teeth, with chlorhexidine gel

– Stimulation of the oral mucosa 2th hourly with a foam swab to promote salivary flow

– Maintain lip moisturizing every 4 hours with water soluble gel.

In Summary

References• Berry, A. Davidson, P., Masters, J., & Rolls, K. Systematic Literature Review of Oral Hygiene Practices for Intensive Care Patients

Receiving Mechanical Ventilation. American Journal Of Critical Care, 2007; Vol 16, No6, 552 -562.• Berry, A ., Davidson, P., Masters, J., Rolls, K., & Ollerton, R. (2010) “Effects of Three Approaches to Standardized Oral Hygiene to Reduce

Bacterial Colonisation and VAP in Mechanically Ventilated Patients: A Randomised Control Trial”, International Journal o Nursing Studies In print

• Browne, J., Evans, D., Christmas, L., & Rodriguez, M. (2011) “Pursuing Excellence: Development of an Oral Hygiene Protocol for Mechanically Ventilated Patients”, Critical Care Nursing Quarterly , Vol 34, No 1, pp 25 -30.

• Blot,S., Vandijck,D.,& Labeau, S. (2008) “Oral Care of Intubated Patients”, Clinical Pulmonary Medicine Vol.15, Number 3, pp 153 - 160.• Garcia,R., (2005) “ A review of the possible role of oral and dental colonisation on the occurrence of health care – associated

pneumonia: Underappreciated risk and a call for interventions” American Journal of Infection Control, Vol33, No9,pp 527 – 540.• Hutchins,K., Karras, G., Erwin, J., & Sullivan, K. (2008) “Ventilator – associated pneumonia and oral care : A successful quality

improvement project”. American Journal of Infection Control, Vol37, No7, pp 590 – 597.• ICCMU Consensus-based Clinical Guideline for the Provision of Oral Care for theCritically Ill Adult

intensivecare.hsnet.nsw.gov.au/five/doc/intensive%20care%20collaborative%20guidelines/8%20%20Final%20oral%20guideline%20December%205_1.pdf

• Monro, C.L., Grap, M. Elswick, R. & McKinney,J, (2006) Oral Health Status and Development of Ventilated Associated Pneumonia: a descriptive study. American Journal Of Critical Care Vol15, No4, 453 – 460.

• Paji, S., & Scannapieco, F. (2007) “Oral Biofilms, Periodontitis and Pulmonary Infections”. Oral Disease Journal, Vol 13, No6, pp508 -512.• Pear, S. Oral Care is Critical Care: The Role of Oral Care in the Prevention of Hospital –Acquired Pneumonia. Infection Control Today,

2007; Vol11, No 10.• Safdar, N., Crnich, C., & maki, D. (2005) “ The Pathogenesis of Ventilator – Associated Pneumonia: Its relevance to Developing Effective

Strategies for Prevention, Respiratory Care , Vol 50, No6, pp 725 – 741.• Stonecypher, K. (2010)” Ventilator – Associated Pneumonia: The Importance of Oral Care in Intubated Patients”, Critical Care Nursing

Quarterly , Vol 33, No 4, pp 339 – 347.