The Bedside Oral Exam and the Barrow Oral Care Protocol: translating evidence-based oral care into practice

Evaluation of clinical oral care outcomes according to nursing outcomes classification

PURPOSE

This research was planned to follow the healing process of the oral mucosa in patients in intensive care with an "Impaired Oral Mucous Membrane Integrity" nursing diagnosis based on the "NOC (1100) Oral Health Assessment" outcome criteria.

METHOD

This study, which was planned in a methodological and descriptive type of research, was carried out with 50 patients who were hospitalized in the intensive care clinic of a state hospital between June and December 2022, with a nursing diagnosis of "Impaired Oral Mucous Membrane Integrity." Data were collected using a Patient Information Form and the "NOC (1100) Oral Health Evaluation Scale" for the nursing outcomes classification. In the analysis of the data descriptive statistical methods, Pearson correlation test, Friedman test as well as Cohen's kappa test were used to evaluate the agreement between two independent observers.

FINDINGS

In the study, content validity index value of the NOC scale was calculated to be 0.90. The examination of the participants' mean scores on the NOC (1100) Oral Health Assessment Scale showed that there were statistically significant differences in terms of the repeated evaluations, except for the NOC indicators of "Oral mucosal integrity," "Gum integrity," and "Tooth integrity" (p < 0.01). No statistically significant correlation was found between the mean NOC scale scores of the patients according to the variables of age, body mass index, mechanical ventilation time, and length of stay in the intensive care unit (p > 0.05).

CONCLUSIONS

The findings showed that the Turkish version of NOC (1100) Oral Health Assessment Scale was a valid tool for monitoring the healing process of the oral mucosa in patients in intensive care.

IMPLICATIONS OF NURSING PRACTICE

With the use of NOC (1100) Oral Health Assessment Scale, a common language will be formed in the evaluation for monitoring the healing process of the oral mucosa in nursing care.

Assessment of the Oral Health Status of Patients Admitted to Pediatric Intensive Care Units: A Cross-Sectional Study

BACKGROUND

It is important to detect oral health problems early among patients admitted to pediatric intensive care units to establish the diagnosis and consequently allow nurses to plan appropriate oral care practices.

OBJECTIVES

The study aimed to assess the oral health status of patients admitted to pediatric intensive care units.

METHODS

This descriptive cross-sectional study was conducted from June to September 2021 in the pediatric intensive care units of 3 hospitals. A total of 88 children were included in the study. An intraoral assessment was performed using a tongue depressor and a flashlight, and data were collected using a patient information form and the Oral Assessment Guide (OAG).

RESULTS

The mean OAG score was 8.45 ± 2.876 points. A significant difference was found in the OAG score between the patients 60 months or younger and those 61 months or older (P < .05). The OAG score was significantly associated with the use of diuretics (P < .05) and the frequency of oral care (P < .05). A negative relationship was found between the OAG score and the Glasgow Coma Scale score (P < .05).

CONCLUSIONS

The oral health status of the patients worsened as their age increased, and their state of consciousness decreased. Oral care was more frequently applied to the patients who received artificial respiration. The study provides evidence-based data regarding the early detection of the factors threatening oral health and the necessary precautions.

Cross-cultural adaptation and validation of the Chinese version of the intensive care oral care frequency and assessment scale

Objectives

The objective of this study was to translate the Intensive Care Oral Care Frequency and Assessment Scale into Chinese and to evaluate its reliability and validity in Chinese ICU patients.

Methods

This study was conducted using a cross-sectional survey design in ICUs of three tertiary hospitals in Huai'an and Taizhou from October 2022 to April 2023. The Chinese version of the Intensive Care Oral Care Frequency and Assessment Scale (C-ICOCFAS) was developed by expert consultation and cultural adaptation according to the two-person verbatim translation-back translation criteria described in the Brislin model. Item analysis was conducted using correlation analysis, and validity analysis included content validity, construct validity, and criterion validity. Reliability analyses included Cronbach's alpha coefficient, Guttman split-half reliability, and interrater reliability.

Results

The Chinese version of the scale consisted of one dimension and nine items, consistent with the original version. Exploratory factor analysis showed KMO = 0.891, and the cumulative variance contribution reached 65.534 %. The confirmatory factor analysis indicated a good fit, χ2/df = 2.124, NFI = 0.950, GFI = 0.942, IFI = 0.973, CFI = 0.973, SRMR = 0.037, and RMSEA = 0.073. The content validity of the scale was 0.97, and the content validity of the items ranged from 0.83 to 1.00; the criterion validity was 0.969; the Cronbach's alpha coefficient was 0.919; the total item correlation coefficient was 0.725-0.831; the Guttman split-half reliability was 0.919; and the interrater reliability was 0.885.

Conclusion

The C-ICOCFAS has good reliability and validity and can effectively guide nurses in the frequency of oral care for ICU patients.

Implications for clinical practice

This tool can significantly improve the level of oral care among ICU patients and further promote the health and safety of patients. These findings can help clinical nursing experts to better understand and master the use of scales and standards to improve nursing.

Oral health care in adult intensive care units: A national point prevalence study

BACKGROUND

The importance of good oral hygiene for patients in Intensive Care Units (ICUs) is well recognized, however, the most effective way to achieve good oral care in the ICU is unclear.

AIM

This study aimed to provide a national picture of oral care practices in adult ICUs in the United Kingdom (UK) to identify areas for improvement.

STUDY DESIGN

A national one-day point prevalence study was undertaken in adult ICUs in the UK in the period from 30th September to 14th October 2021. Data were collected on all patients in the ICU on the date of data collection. Using a validated electronic data collection form, anonymised data were collected on methods and frequency of oral care provided, and the use of oral care protocols within the ICU. Data were analysed using descriptive analysis.

RESULTS

Data from 195 patients in 15 ICUs in England, Wales and Northern Ireland were collected. Written oral care protocols were available for use in the care of 65% (n = 127) of patients. 73% (n = 142) of patients received oral care within the 24-h period. Oral care methods included toothbrushing 41% (n = 79), foam sticks 3% (n = 5), moisturizing the oral cavity 10% (n = 19) and mouth rinse with chlorhexidine 3% (n = 5) and other oral care methods not specified 12% (n = 23). 44% (n = 85) of patients had an oral assessment within the 24-h period and variable assessment methods were used.

CONCLUSION

There is large variability in oral care provision and methods for intubated ICU patients and a lack of consensus was revealed in the study. Oral assessment is conducted less frequently using multiple tools. Optimal oral care standards and further research into oral care provision is pivotal to address this important patient-relevant practice.

RELEVANCE TO CLINICAL PRACTICE

Oral care is a fundamental part of care for ICU patients, however, there is a large degree of variability, and oral care is often not based upon oral assessment. The use of an oral care protocol and oral assessments would help to improve patient care, ease of use for staff and provide a tailored oral care plan for patients, improving efficiency and preventing wasted resources.

Provision of Oral Care in the Cardiothoracic Intensive Care Unit: Survey of Nursing Staff Training, Confidence, Methods, Attitudes, and Perceived Barriers

BACKGROUND

Poor oral health is associated with adverse outcomes in critical care settings. Although provision of oral care is a fundamental aspect of nursing practice, both formal training and practice among nursing staff remain unclear.

METHOD

Cardiothoracic intensive care unit nurses were recruited to complete a 16-item survey regarding training, confidence, methods, prioritization, and barriers to provision of oral care.

RESULTS

A total of 108 nurses participated (70% response rate). Formal training in oral care was reported by 38%, most frequently reported as less than 1 hour (53%) in duration. Of the respondents, 70% reported confidence in providing oral care. Nine methods and 16 products were identified, with variability in the frequency of provision. Prioritization of oral care was rated most frequently as moderate (53%), with 28% reporting barriers.

CONCLUSION

Despite limited formal training, surveyed nurses reported confidence in providing oral care. Methods, frequency, and prioritization were variable. Both development of formal curricula and evaluation of adherence to standardized protocols for oral care are warranted. [J Contin Educ Nurs. 2023;54(7):313-321.].

Best Practices in Oral Care

Topic

Assessing functional cognition is a critical need for intensive care unit survivors transitioning to another level of care.

Clinical Relevance

Up to 62% of patients discharged from an intensive care unit have significant cognitive impairment that is not associated with severity of illness, number of comorbidities, or length of hospital stay. For more than 20 years, researchers have published an array of potentially effective interventions, including case management, patient and informal caregiver education, and home health care services.

Purpose

To describe the impact of and potential interventions for cognitive decline at intensive care unit discharge and discharge readiness on 30-day readmission rates.

Content Covered

Assessing the patient’s functional cognition assessment and advocating for appropriate resources are needed to improve patient and clinical outcomes.

Oral care in intensive care units: Lithuanian nurses' attitudes and practices

AIM

This study examines the attitudes and practices of ICU nurses towards the provision of oral care to their patients.

OBJECTIVE

We conducted this cross-sectional survey about oral health care practices in ICUs in Lithuania.

METHODS

We used a self-administered 20-item questionnaire to survey the current oral care practices, training, and attitudes of 108 nurses. The questionnaire was based on previous studies to gather information related to the attitudes, oral care practices, and training of ICU nurses. We used the chi-square test to analyze relationships between the categorical variables.

RESULTS

Most (88, 82%) of the nurses stated that oral care is important. Although most (83, 77%) had adequate training, a clear majority (98, 91%) of the nurses reported a willingness to learn more. Most (78, 72%) of the nurses found the oral cavity difficult to clean, and (71, 66%) found doing so unpleasant. When performing oral care, the nurses used mostly foam swabs (62, 61%) and moisturizers (54, 53%). More than half (57, 57%) of the nurses expressed a need for more hospital support.

CONCLUSIONS

Nurses working in ICUs reported that oral care is a high priority for their patients, but a difficult and unpleasant task. Nurses provided oral care mainly with toothbrushes, foam swabs, and moisturizers.

The effect of oral care using honey as an additional topical agent on oral health status of intubated patients in the intensive care unit

BACKGROUND

Patients using endotracheal tubes are at high risk of oral health status dysfunction due to impaired natural airway defence, oral flora composition changes and protective substances of the teeth, medication causing xerostomia. Oral care has not been enough to manage oral mucosal dryness, so an additional topical agent is needed to protect oral mucosa to maintain oral health. Honey is one of the recommended topical agents.

OBJECTIVE

This study aims to identify the effect of oral care with honey as topical agents on the oral health status of patients using endotracheal tube in the Intensive Care Unit.

METHODS

This was an experimental study with a randomized pretest and posttest design. The sample was adult intubated patients, consisting of 36 patients. The data were analysed using the parametric test, and dependent and independent t-test.

RESULTS

The oral health score in the control group was found to be pre & post mean score11.94 and 13.28 (p=.004) respectively, while in the intervention group 11.89 and 8.33 (p<.001). Mean differences in both groups were 4.95 (p<.001) and the BOAS subscale differences were seen on the lips, gums & mucosa, and tongue (p<.05).

CONCLUSION

Oral care with honey as a topical agent can improve the oral health status of intubated patients on the lips, gum, mucosa, and tongue subscale. Therefore, honey as an additional topical agent can be a moisturizer to maintain the oral mucosa for intubated patients in the Intensive Care Unit. Furthermore, good mucosal health will help prevent the infection and colonization of microorganisms.

Comparison of the Amount of Used and the Ease of Oral Care between Liquid and Gel-Type Oral Moisturizers Used with an Oral Care Simulators

Oral care involving the removal of dry sputum is effective for older patients who require nursing care or hospitalization. However, safe and efficient oral care methods for such patients remain unclear. We aimed to simulate the oral cavity of older adults with dry mouth and elucidate the differences between two moisturization agents, water and gel-like oral moisturizer, and investigate the effect of occupation and experience on the amount of use and the ease of oral care. Using an oral care simulator (MANABOT^®, Nissin Dental Products Inc., Kyoto, Japan), 42 students and 48 dental professionals (13 dentists and 35 dental hygienists) performed oral care using moisturization agents to facilitate dry sputum removal. The time required for oral care, amount of water or gel used, amount of pharyngeal inflow, and ease of oral care when using water or gel were compared. The simulations revealed that the amount of use and pharyngeal inflow for gel (2.9 ± 1.6 and 0.3 ± 0.3, respectively) were significantly lower than those for water (6.8 ± 4.1 and 1.2 ± 1.5, respectively) in all participants. Using a gel-like moisturizer might reduce the aspiration risk in older patients requiring nursing care or hospitalization, regardless of occupation and experience.

Severe oral mucositis relating to pain and worse oral condition among patients with solid tumors undergoing treatment with FOLFIRI and 5-FU: a retrospective study

BACKGROUND

There is a need for studies that correlate the severity of oral mucositis (OM) with chemotherapy protocols, transient myelosuppression and oral health.

OBJECTIVE

To analyze the severity of OM among individuals with solid tumors during hospitalization and its correlation with the type of chemotherapy, myelosuppression and oral health condition.

DESIGN AND SETTING

Retrospective study at a public hospital in Bauru, state of São Paulo, Brazil, that is a regional referral center.

METHODS

Individuals diagnosed with solid malignant tumors who received chemotherapy during hospitalization for completion of the antineoplastic treatment cycle or who presented complications resulting from this were assessed.

RESULTS

Twenty-eight individuals (24.3%) manifested some degree of OM. The most prevalent degrees of OM according to the World Health Organization (WHO) and modified WHO classification were grades 2 (11.3%) and 5 (4.3%), respectively. It was observed that the higher the OM-WHO (P < 0.001; r = 0.306) and modified OM-WHO (P < 0.001; r = 0.295) classifications were, the greater the oral pain reported by the individuals was. Presence of mucositis in the upper lip and buccal mucosa contributed to increased severity of OM and worsening of swallowing during hospitalization. Thus, severe OM was associated with use of the FOLFIRI protocol (folinic acid, fluorouracil and irinotecan).

CONCLUSION

Individuals with tumors who presented severe OM had greater severity of oral pain and worse oral health. Use of the FOLFIRI protocol was associated with higher prevalence of severe OM, while use of 5-fluorouracil (5-FU) was correlated with worse oral condition.

Clinical Statistics of Dysphagia Rehabilitation Provided on Dental Visits to a Partner Hospital

Maintaining oral hygiene is an important yet often neglected aspect of rehabilitation medicine. Our visiting dental team, which provides dental treatments and swallowing rehabilitation, partnered with a medical hospital that had no dental department and began visiting and treating inpatients at this hospital. This study is aimed at evaluating the effects of dysphagia rehabilitation, and this was jointly conducted by medical and dental hospitals. The survey was conducted between May 2017 and March 2018. We retrospectively examined dysphagia rehabilitation provided to 25 patients (12 men and 13 women) aged 40–92 years (mean age: $77.1\pm 12.3$ years). The largest number of requests for dental treatment was received from the internal medicine department (13 requests, 52.0%). A total of 39 videofluoroscopic or videoendoscopic examinations of swallowing interventions for dysphagia rehabilitation were conducted. All patients’ oral and swallowing functions were evaluated using the functional oral intake scale (FOIS). At initial assessment, 9, 13, and 0 patients were at FOIS levels 1, 2, and 3 (use of tube feeding), respectively, and 1, 2, and 0 patients were at FOIS levels 4, 5, and 6 (only oral feeding), respectively. At the final assessment, 6, 10, and 4 patients were at FOIS levels 1, 2, and 3, respectively, and 0, 2, and 3 patients were at FOIS levels 4, 5, and 6, respectively. Oral and swallowing functions differed significantly between the first and final visits ( $p=0.02$ ). Visits conducted by a team of oral health practitioners to a medical hospital without a dental department appear to have a major impact and will become even more important in the future.

Effectiveness of Standard Oral Care Plan During Hospital Stay in Individuals With Brain Injury

Objective: To investigate the effectiveness of an existing standard oral care program (SOCP) and factors associated with it during hospitalization in individuals with acquired brain injury (ABI).

Material and Methods: A total of 61 individuals underwent a SOCP for 4 weeks in a longitudinal observational study. Rapidly noticeable changes in oral health were evaluated by performing plaque, calculus, bleeding on probing (BOP) and bedside oral examination (BOE) at weeks 1 and 5. Individuals' brushing habits, eating difficulties, and the onset of pneumonia were retrieved from their medical records. Association between oral-health outcomes to systemic variables were investigated through multilevel regression models.

Results: Dental plaque (P = 0.01) and total BOE score (P &lt; 0.05) decreased over time but not the proportion of dental calculus (P = 0.30), BOP (P = 0.06), and tooth brushing frequency (P = 0.06). Reduction in plaque and BOE over time were negatively associated with higher periodontitis scores at baseline (coef. −6.8; −1.0), respectively, which in turn were associated with an increased proportion of BOP (coef. ≈ 15.0). An increased proportion of calculus was associated with eating difficulties (coef. 2.3) and the onset of pneumonia (coef. 6.2).

Conclusions: Nursing care has been fundamental in improving oral health, especially reducing dental plaque and BOE scores. However, our findings indicate a need for improving the existing SOCP through academic-clinical partnerships.

Clinical Relevance: Early introduction of oral care program to brain-injured individuals is beneficial in reducing plaque accumulation and improving oral health.

Nurses' practices and obstacles to oral care quality in intensive care units in Upper Egypt

BACKGROUND

Oral care is one of the fundamental nursing care procedures used to decrease oral colonization, dental plaque, respiratory infections, and patient stay and cost.

AIMS

This study aimed to identify intensive care unit (ICU) nurses' self-assessment of oral care frequency, skill competency, documentation, oral care tools, and obstacles to oral care quality. In addition, it proposed exploring associations between nurses' attitudes about the importance of oral care and the priority of other interventions.

STUDY DESIGN AND SETTING

A cross-sectional descriptive study was conducted in two ICUs (trauma and general) in the main teaching hospital in Upper Egypt. Of 105 nurses selected using convenience sampling, 91 completed the questionnaire.

RESULTS

About 60.4% of ICU nurses did not attend any oral care training programme, 40.7% reported performing oral care four times per shift in intubated patients, 62.6% reported that their skills needed improvement, 37.4% saw themselves as competent, and 86.8% documented oral care in patients' records. Significant positive correlations were found, indicating that nurses' attitudes towards the importance of oral care showed the same tendency as the priority given to other interventions, such as eye care, bowel care, documentation, hygiene, catheters, feeding, and wound care (correlation coefficient [r] = 0.290, 0.511, 0.333, 0.425, 0.431, 0.345, and 0.337, respectively). Furthermore, a toothbrush (84.6%) was often used, while chlorhexidine was not used (90.1%). The major obstacles to the provision of oral care as perceived by the nurses were the fear of aspiration and life-threatening interventions (95.6%), inadequate nurse-patient ratios (94.5%), irregular competency evaluations (92.3%), unavailability of oral care guidelines (92.3%), and shortage of time (84.6%).

CONCLUSION

The participating nurses were mindful of the importance and priority of oral care. Many of them did not attend oral care training programmes and considered that their skills needed improvement. Moreover, ICU nurses reported many obstacles hindering oral care quality.

RELEVANCE TO CLINICAL PRACTICE

This research identifies the importance of developing in-service oral care training programmes to improve ICU nurses' skill competency. High-quality oral care can be provided by focusing on and overcoming obstacles that hinder nurses' oral care practice.

Internal structure and validity of the bedside oral examination tool in patients with brain injury at neurorehabilitation setting

OBJECTIVES

To assess the internal structure and validity of the 'bedside oral examination' (BOE) instrument in individuals with acquired brain injury (ABI).

METHODS

Ninety ABI individuals were examined using BOE in their first week of neurorehabilitation. BOE measures oral health within eight categories including: swallow, tongue, odour, teeth, lips, saliva, mucosa and gingiva. To assess the validity of BOE, full-mouth clinical examination (gold standard) was performed. The internal structure of BOE was assessed using exploratory and confirmatory factor analyses. To measure the validity, the BOE scores were dichotomised into excellent oral health and altered oral health. Sensitivity, specificity and area under the receiver operating characteristic (ROC) curve of the six/eight BOE items were compared with their related clinical oral examination tool.

RESULTS

Overall, the patients had poor oral health irrespective of the oral examination tool used. Factor analyses indicated two factors within BOE: 'oral hygiene' (teeth, gingiva and mucosa) and 'orofacial health' (lips, swallow and saliva). BOE tongue and odour items loaded in neither factor. BOE items showed low validity since the highest area under the ROC curve was 0.60. Findings on the sensitivity value ranged from 35.0 to 74.2, while specificity from 44.4 to 83.3, depending on the item evaluated.

CONCLUSION

Bedside oral examination does not seem to be an ideal 'single' outcome tool in a neurorehabilitation setting as it lacks validity. BOE evaluates oral health as two independent but correlated components and treat them separately indicating precision treatment depending on their oral health dysfunction. It is advisable to use BOE as a screening tool. However, it should be complimented by proper clinical examination before establishing a treatment plan for oral health in patients with ABI.

Oral health care for the critically ill: a narrative review

Background

The link between oral bacteria and respiratory infections is well documented. Dental plaque has the potential to be colonized by respiratory pathogens and this, together with microaspiration of oral bacteria, can lead to pneumonia particularly in the elderly and critically ill. The provision of adequate oral care is therefore essential for the maintenance of good oral health and the prevention of respiratory complications.

Main body

Numerous oral care practices are utilised for intubated patients, with a clear lack of consensus on the best approach for oral care. This narrative review aims to explore the oral-lung connection and discuss in detail current oral care practices to identify shortcomings and offer suggestions for future research. The importance of adequate oral care has been recognised in guideline interventions for the prevention of pneumonia, but practices differ and controversy exists particularly regarding the use of chlorhexidine. The oral health assessment is also an important but often overlooked element of oral care that needs to be considered. Oral care plans should ideally be implemented on the basis of an individual oral health assessment. An oral health assessment prior to provision of oral care should identify patient needs and facilitate targeted oral care interventions.

Conclusion

Oral health is an important consideration in the management of the critically ill. Studies have suggested benefit in the reduction of respiratory complication such as Ventilator Associated Pneumonia associated with effective oral health care practices. However, at present there is no consensus as to the best way of providing optimal oral health care in the critically ill. Further research is needed to standardise oral health assessment and care practices to enable development of evidenced based personalised oral care for the critically ill.

Importance of postural change for accidental ingestion of dental prostheses: a case report

Accidental ingestion of dental prostheses requires immediate emergency action. The authors report a case of accidental ingestion of a dental prosthesis in a patient with a disorder of consciousness. The accidental ingestion was diagnosed by imaging examination, and the location of the dental prosthesis was explored under general anesthesia according to the preoperative examination images. However, no dental prosthesis was found in the hypopharyngeal region. The operators found a radiopaque region in the nasopharynx that was suspicious of a dental prosthesis by X-ray examination of the head and neck region. According to the X-ray examination, the dental prosthesis was removed from the nasopharynx. The patient’s postoperative course was uneventful. Postural change for cases of accidental ingestion of dental prostheses may be a simple and important lifesaving step in addition to traditional methods.

Oral health status of inpatients with varying physical activity limitations in rehabilitation wards: A cross-sectional study

Poor oral hygiene can be potentially life-threatening in inpatients. However, no basic protocol on oral hygiene customized for inpatients exists, and lack of oral care related knowledge, attitude, and skills among caregivers could be detrimental to the general health of patients. This study sought to identify the oral care practices and oral health status of inpatients with varying physical activity limitations in a rehabilitation ward.Sixty-one inpatients in a rehabilitation ward were evaluated for their medical and physical conditions and oral health status. These were assessed using the bedside oral exam, decayed, missing, filled teeth index, plaque index, gingival index, and caries activity test.In total, 40 men and 21 women (mean age, 56.6 years) were included in this study. Among them, 50.8% of the patients could brush their teeth unassisted, whereas 49.2% required assistance from an assistant for oral care. The proportion of patients receiving nasogastric tube feeding was higher in the group that could not provide oral self-care; 36.7% and 33.3% of these patients showed moderate and severe dysfunction, respectively, based on bedside oral exam. Scores for the swallowing, tongue, and total domains of bedside oral exam were poorer for patients who could not provide oral self-care (P < .01). The caries activity test indicated a moderate risk for both groups.Our findings suggest that an oral care protocol that considers the physical activity limitations in inpatients in rehabilitation wards is necessary to minimize negative influences on the systemic health of these patients.

Association between the point-rating system used for oral health and the prevalence of Gram-negative bacilli in hematological inpatients: A retrospective cohort study

Gram-negative bacteremia is a major cause of death among hematology inpatients who require heavy-dose chemotherapy and hematopoietic stem cell transplantation. Gram-negative bacillus (GNB) is more likely to be detected when the oral health is poor. However, there is a dearth of studies on the relationship between oral assessment and prevalence of GNB in hematology inpatients.This retrospective study aimed to evaluate the relationship between the original point-rating system for oral health examinations (point-oral exam) and the prevalence of GNB in hematology inpatients at the hematology ward of the Yamanashi University Hospital. GNB was detected by cultivating samples from the sputum and blood of each patient.A total of 129 subjects underwent a medical checkup and point-oral exam. The sputum and blood culture results of 55 patients were included in this study. The total points of patients positive for GNB (n = 25, 45.5%) were significantly higher than those who were negative for GNB (total score: median, 25th, 75th, percentile; 6 [4, 7] vs 2 [1, 4]; P = .00016). Based on the receiver operating characteristic analysis, a cutoff score of 5 proved to be most useful to detect GNB.An oral evaluation with a cutoff value of 5 or higher in the point-oral exam might indicate the need for a more thorough oral management to prevent the development of systemic infections from GNB.

Evaluation and Acceptance of an Electric Toothbrush Designed for Dependent Patients

INTRODUCTION

A key barrier to standardizing evidence-based oral health protocols for highly dependent patients is the lack of validated and accepted oral health products designed specifically for use by caregivers. This study compared preferences by users of a novel electric toothbrush and a manual toothbrush in a health care setting.

METHODS

We prospectively enrolled health care providers as volunteers. Volunteer brushers completed simulated tooth brushing sessions of mock-intubated and non-intubated volunteer brushees with both toothbrushes. Volunteers rated different domains of toothbrush preference in an anonymous, optional survey.

RESULTS

A total of 133 health care providers volunteered (123 brushers [providers brushing teeth] and 10 brushees [those having their teeth brushed]). The novel electric toothbrush received significantly higher positive ratings than the standard hospital-issue manual toothbrush in all domains that we surveyed: ease of use, thoroughness, safety, shape and size of the brush head, overall cleanliness, time requirements, and efficiency (p<0.001). Importantly, due to the integrated light and suction of this electric toothbrush, brushers completed more sessions without setting down the toothbrush with the electric toothbrush than with the manual toothbrush (75.4% vs 36.4%; p<0.001).

CONCLUSIONS

Integrating a lighted electric brush with suction into the caregiver's armamentarium as an evidence-based tool is warranted and should be evaluated in terms of patient outcomes.

Changes in oral health related quality of life and its associated factors in individuals with brain injury

Purpose: To evaluate changes in oral health-related quality of life (OHRQoL) and associated factors in individuals with acquired brain injury (ABI) during hospitalization.Methods: Forty-six individuals with ABI were examined at week 1 and 5 of hospitalization. OHRQoL was recorded through Oral Health Impact Profile-14 (OHIP-14), clinical oral examinations were conducted, while orofacial health-related 'motor' and 'cognitive' scores were retrieved from patients' e-journal. Association between variables were investigated using factor analysis and multilevel regression modeling.Results: There were no significant differences in the OHIP-14 scores between week 1 and 5. Factors analysis revealed two OHIP-14 domains, 'psychosocial' and 'physica'. Individuals who improved their cognitive skills over study period and those with 'severe' periodontitis at baseline had increased scores of OHIP-14 'psychosocial' domain. Individuals who improved orofacial health-related 'motor' skills over study period had decreased 'physical' domain scores. Increased cognition over study period, current smoking and dental calculus were associated with increased 'physical' domain.Conclusions: The OHRQoL was poor both at week 1 and 5. Individual's cognitive and motor skills as well as their oral health status influenced their OHRQoL. Thus, individual's awareness and involvement in addition to oral care seem to be imperative in improving the OHRQoL in neurorehabilitation setting.

British Association of Critical Care Nurses: Evidence-based consensus paper for oral care within adult critical care units

BACKGROUND

Patients who are critically ill are at increased risk of hospital acquired pneumonia and ventilator associated pneumonia. Effective evidence based oral care may reduce the incidence of such iatrogenic infection.

AIM

To provide an evidence-based British Association of Critical Care Nurses endorsed consensus paper for best practice relating to implementing oral care, with the intention of promoting patient comfort and reducing hospital acquired pneumonia and ventilator associated pneumonia in critically ill patients.

DESIGN

A nominal group technique was adopted. A consensus committee of adult critical care nursing experts from the United Kingdom met in 2018 to evaluate and review the literature relating to oral care, its application in reducing pneumonia in critically ill adults and to make recommendations for practice. An elected national board member for the British Association of Critical Care Nurses chaired the round table discussion.

METHODS

The committee focused on 5 aspects of oral care practice relating to critically ill adult patients. The evidence was evaluated for each practice within the context of reducing pneumonia in the mechanically ventilated patient or pneumonia in the non-ventilated patient. The five practices included the frequency for oral care; tools for oral care; oral care technique; solutions used and oral care in the non-ventilated patient who is critically ill and is at risk of aspiration. The group searched the best available evidence and evaluated this using the Grading of Recommendations Assessment, Development, and Evaluation system to assess the quality of evidence from high to very low, and to formulate recommendations as strong, moderate, weak, or best practice consensus statement when applicable.

RESULTS

The consensus group generated recommendations, delineating an approach to best practice for oral care in critically ill adult patients. Recommendations included guidance for frequency and procedure for oral assessment, toothbrushing, and moisturising the mouth. Evidence on the use of chlorhexidine is not consistent and caution is advised with its routine use.

CONCLUSION

Oral care is an important part of the care of critically ill patients, both ventilated and non-ventilated. An effective oral care programme reduces the incidence of pneumonia and promotes patient comfort.

RELEVANCE TO CLINICAL PRACTICE

Effective oral care is integral to safe patient care in critical care.

Development of an intensive care oral care frequency assessment scale

BACKGROUND

Oral care and frequency of oral care is important for intensive care patients in order to prevent the risk of ventilator-associated pneumonia. However, there are no scales to assess the frequency of oral care specific to intensive care units (ICUs).

AIMS AND OBJECTIVES

This study aimed to develop a valid and reliable tool, "Intensive Care Oral Care Frequency Assessment Scale (ICOCFAS)", for assessing the frequency of nurses' oral care in critical ill patients.

DESIGN

This was an instrument development study.

METHODS

The validity and reliability of the ICOCFAS, which consists of nine items, were tested using content validity (five expert opinions), construct validity (factor analysis), item analysis, and internal consistency analysis methods. The population of the research consisted of inpatients at the ICU of a hospital in Sakarya, Turkey. The research was conducted with 73 patients in the ICU.

RESULTS

Expert opinions on the content validity indicated that the scale was admissible. The Kaiser-Meyer-Olkin (KMO) coefficient was calculated at 0.800, and the Chi-square value of the Bartlett test was considerably significant (χ² = 270.539; P < .001). Using a path diagram in confirmatory factor analysis, Chi-square/df ratio values were calculated as 1.49, standardized root mean square residual as 0.077, comparative fit index as 0.97, and root mean square error of approximation as 0.082. Cronbach's alpha was 0.851. The correlations between the items and total scores were 0.455 to 0.835 and were statistically significant (P < .001).

CONCLUSIONS

The ICOCFAS is an efficient tool with high validity and reliability for assessing oral care frequency in the ICU.

RELEVANCE TO CLINICAL PRACTICE

The ICOCFAS is a valid and reliable tool for Turkish society for assessing the frequency of oral care of patients in the ICU. It is recommended for various national and international studies with different patients in ICUs.

Improving oral care for hospitalised patients: choosing appropriate products

BACKGROUND

Oral care is a fundamental part of nursing but it is often performed as a routine task, often based on historic practice, and lacks an evidence base. A variety of oral care products are used in practice.

AIM

To discover evidence of effective oral care products for use in hospitalised patients.

DESIGN

A systematic literature review was undertaken.

METHODS

A review of articles was conducted using CINAHL, PubMed, the Cochrane Database and Google Scholar between 2007 and 2019. All articles were compared and contrasted and some excluded due to the quality of the evidence.

DISCUSSION

The literature review identified a number of oral care problems and investigated a range of products.

RESULTS

The main finding was that there is a need for a definitive, evidence-based oral care guideline on the products suitable for different oral care conditions, including dysphagia, xerostomia, mucositis, and for patients wearing dentures.

Oral Health Status of Hospitalized Patients With Type 2 Diabetes

BACKGROUND

Diabetes is associated with poor oral health, as well as reduced access to dental care. A large percentage of patients hospitalized in the United States carry a diagnosis of diabetes; however, the oral health status of patients with diabetes who are hospitalized is unknown.

METHODS

All patients meeting inclusion criteria on the general medicine service of a tertiary care hospital were invited to participate. Subjects were asked about their access to dental care and perceptions of their oral health. A dental hygienist conducted examinations, including decayed, missing, and filled teeth (DMFT) and periodontal screening and recording (PSR) indices on a subset of subjects.

RESULTS

The 105 subjects had a mean age of 69 ± 12 years and a median A1C of 7.5 ± 2.1%. Rates of comorbidity and polypharmacy were high. The mean number of DMFT was 23.0 ± 7.2, with 10.1 ± 7.2 missing teeth. Forty- four percent of subjects had a removable prosthesis. Sixty-eight percent had a PSR index ≥4 in at least one sextant, indicating moderate periodontal disease.

CONCLUSION

Rates of missing teeth, removable prostheses, and periodonal inflammation were high among hospitalized patients with diabetes, but patients did not perceive their oral health to be poor. Health care providers should be aware of the oral health risks of patients with diabetes during hospitalization, and dentists should consider screening patients with diabetes for recent hospitalization.

Electric brushes improve outcomes in caregiver-assisted oral hygiene

An effective means of maintaining oral health is imperative for the health of long-term-care patients. This article assesses oral hygiene using an electric toothbrush compared with a manual toothbrush.

Intensive care nurses fail to translate knowledge and skills into practice - A mixed-methods study on perceptions of oral care

OBJECTIVES

To identify intensive care nurses' perceptions of oral care according to Coker et al.'s (2013) conceptual framework and to contribute to the knowledge base of oral care in intensive care.

DESIGN/METHODS

This was a concurrent embedded mixed-methods design, with more weight given to the quantitative part. Participants responded to the Nursing Care related to Oral Health questionnaire, including perceptions of oral care antecedents (18 items), defining attributes (17 items), and consequences (6 items) and two open-ended questions. The data were analysed with descriptive and correlation statistics and qualitative content analysis.

SETTING

Intensive care nurses (n = 88) in six general intensive care units.

RESULTS

Intensive care nurses perceived that an important part of nursing care was oral care, especially to intubated patients. They perceived that the nursing staff was competent in oral care skills and had access to different kinds of equipment and supplies to provide oral care. The oral cavity was inspected on a daily basis, mostly without the use of any assessment instruments. Oral care seemed to be task-oriented, and documentation of the patients' experiences of the oral care process was rare.

CONCLUSIONS

The antecedents, knowledge and skills are available to provide quality oral care, but intensive care nurses seem to have difficulties translating these components into practice. Thus they might have to shift their task-oriented approach towards oral care to a more person-centred approach in order to be able to meet patients' needs.

Comparison of wiping and rinsing techniques after oral care procedures in critically ill patients during endotracheal intubation and after extubation: A prospective cross-over trial

AIM

Endotracheal intubation of critically ill patients increases the risk of aspiration pneumonia, which can be reduced by regular oral care. However, the rinsing of the residual oral contaminants after mechanical cleaning carries the risk of aspirating the residue during the intubation period. Removing the contaminants by wiping with mouth wipes could be an alternative to rinsing with water because of no additional fluid. This study tested: (i) the amount of oral bacteria during endotracheal intubation and after extubation; and (ii) the changes in the bacterial count during oral care procedures.

METHODS

Thirty-five mechanically ventilated patients in the intensive care unit were enrolled. The amount of bacteria on the dorsal tongue surface was counted before and following oral care and then after the elimination of contaminants either by rinsing with water and suctioning or by wiping with mouth wipes. The oral bacterial amount was compared statistically between the intubation and extubation status and among set time points during the oral care procedure.

RESULTS

The oral bacterial count was significantly decreased after extubation. During the oral care procedure, the oral bacterial amount was significantly lower after eliminating the contaminants either by rinsing or wiping, with no remarkable difference between the elimination techniques.

CONCLUSIONS

The findings suggest that the oral bacterial amount is elevated during endotracheal intubation, which could increase the risk of aspiration pneumonia. The significant reduction in the bacterial count by wiping indicates that it might be a suitable alternative to rinsing for mechanically ventilated patients.

Examination of intensive care unit patients' oral health

BACKGROUND

Oral health problems are common complications that most intensive care unit patients experience. There are many factors that affect oral health negatively and nurses have important responsibilities in this regard.

AIM

The aim of this study was assessment of the intensive care unit patients' oral health and risk factors.

METHODS

This study was planned as a descriptive study and conducted between December 2015 and June 2016, with 202 patients in 20 intensive care units of 6 hospitals in Turkey. Data were collected via Data Collection Form and Bedside Oral Exam guide. Oral health assessment of patients was made using a source of light and a tongue depressor.

RESULTS

We observed a significant difference in score of the Bedside Oral Exam guide by age, consciousness, type of respiration and feeding, the frequency of oral health, the total number of drugs, and technique of oral care (P < 0.05). None of the intensive care units were using the oral assessment guide.

CONCLUSION

The result of this study shows that there are various risk factors that adversely affect the oral health of intensive care unit patients. Nurses should undertake assessments on the basis of oral care protocols for patients at risk and carry out evidence-based individualized oral care applications.

Mechanical Ventilation and Cytopathological Changes in the Oral Mucosa

BACKGROUND

The oral mucosa is an important defense barrier to penetration of microorganisms. Thus, changes in the oral epithelium might indicate risk for infection in intensive care patients receiving mechanical ventilation.

OBJECTIVE

To evaluate the oral mucosa of intensive care patients who did or did not receive mechanical ventilation by using liquid-base exfoliative cytology.

METHODS

The sample consisted of 3 groups: 27 patients admitted to intensive care during a 7- to 14-day period who received mechanical ventilation, 29 patients admitted during the same period who did not receive mechanical ventilation, and 27 healthy patients who had no lesions in the mouth. For all 3 groups, samples were collected from the buccal mucosa by using cytology brushes. Smears were applied to glass slides before Papanicolaou staining and were codified for blind analyses by a cytopathologist. Kruskal-Wallis and Dunn tests were used to analyze the results.

RESULTS

Patients receiving mechanical ventilation had higher prevalence and intensity of karyomegaly, perinuclear halos, cell keratinization, deep cells, and leukocyte infiltrates than did patients in the other 2 groups (P < .05). No significant differences were observed between the control group and the group who did not receive mechanical ventilation.

CONCLUSIONS

Liquid-base exfoliative cytology can be used to detect preclinical alterations in the oral mucosa. Patients treated with mechanical ventilation are vulnerable to infections, and oral care may be valuable in their prognosis.

The occurrence of pressure damage in the oral cavity caused by endotracheal tubes

The aim of this observational study was to investigate the occurrence of pressure damage caused by endotracheal tubes (ETT) when the tube is repositioned from one corner of the mouth to the other every third day. For the assessment of oral condition and the eventual damage caused by ETT, a modified version of the Oral Assessment Guide (OAG) was used. The oral condition was assessed once per day in all adult patients who were orally intubated with a tube for over 24 hours. Thirty-eight patients were included in the study. Most patients ( n = 33, 86.8%) had no pressure damage. Five patients (13.2%) had pressure damage on the oral mucosa and lip caused by endotracheal tubes. The group with damage to the oral mucosa was treated with noradrenaline, had bleeding problems and clotting disorders and had significantly more intubated and study days. The assessment of the oral mucosa according to the OAG reflected the worsening oral condition in the group with pressure damage. Endotracheal tubes may need to be repositioned more often than every third day to avoid pressure damage in patients with a high risk of complications, and individually tailored care may need to be implemented.

Comprehensive oral-health assessment of individuals with acquired brain-injury in neuro-rehabilitation setting

PRIMARY OBJECTIVE

To perform a detailed clinical oral health assessment and oral-health-related social and behavioural aspect assessment in individuals with acquired brain injury (ABI).

RESEARCH DESIGN

Prospective observational study.

METHODS AND PROCEDURES

Thirteen individuals with ABI were recruited. Individual's social and behavioural history, bed-side oral examination score (BOE), tooth condition and periodontal status (bleeding, plaque and clinical attachment loss) were thoroughly examined. The entire examination took up to 60 minutes, using proper dental armamentarium.

MAIN OUTCOMES AND RESULTS

All evaluated individuals were diagnosed with chronic generalized periodontitis. A relationship between active periodontal disease and severe BOE score was observed (p = 0.01). Significant interaction between severe BOE scores (≥ 15 or ≥ 14) and periodontal disease severity of ≥ 2 mm (p = 0.01) was observed. The same interaction was seen between severe BOE scores and the combination of 75% extent and 2 mm severity (p = 0.01). Severity and activity of periodontitis showed dependence on individual brushing frequency (p = 0.03 and p = 0.05, respectively).

CONCLUSIONS

Individuals with ABI had a poor status across a range of oral-, dental- and periodontal-related parameters. Further structured studies are required to define evidence-based assessment approaches for such clinical reality.

Applying Adult Ventilator-associated Pneumonia Bundle Evidence to the Ventilated Neonate

BACKGROUND

Ventilator-associated pneumonia (VAP) in neonates can be reduced by implementing preventive care practices. Implementation of a group, or bundle, of evidence-based practices that improve processes of care has been shown to be cost-effective and to have better outcomes than implementation of individual single practices.

PURPOSE

The purpose of this article is to describe a safe, effective, and efficient neonatal VAP prevention protocol developed for caregivers in the neonatal intensive care unit (NICU). Improved understanding of VAP causes, effects of care practices, and rationale for interventions can help reduce VAP risk to neonatal patients.

METHOD

In order to improve care practices to affect VAP rates, initial and annual education occurred on improved protocol components after surveying staff practices and auditing documentation compliance.

FINDINGS/RESULTS

In 2009, a tertiary care level III NICU in the Midwestern United States had 14 VAP cases. Lacking evidence-based VAP prevention practices for neonates, effective adult strategies were modified to meet the complex needs of the ventilated neonate. A protocol was developed over time and resulted in an annual decrease in VAP until rates were zero for 20 consecutive months from October 2012 to May 2014.

IMPLICATIONS FOR PRACTICE

This article describes a VAP prevention protocol developed to address care practices surrounding hand hygiene, intubation, feeding, suctioning, positioning, oral care, and respiratory equipment in the NICU.

IMPLICATIONS FOR RESEARCH

Implementation of this VAP prevention protocol in other facilities with appropriate monitoring and tracking would provide broader support for standardization of care. Individual components of this VAP protocol could be studied to strengthen the inclusion of each; however, bundled interventions are often considered stronger when implemented as a whole.

Advocacy for the Provision of Dental Hygiene Services Within the Hospital Setting: Development of a Dental Hygiene Student Rotation

Educational preparation of dental hygiene students for hospital-based practice, and advocacy efforts promote inclusion of dental hygienists within hospital-based interdisciplinary health care teams.

BACKGROUND AND PURPOSE

Although the value of attending to the oral care needs of patients in critical care units has been recognized, the potential impact of optimal oral health care for the general hospital population is now gaining attention. This article describes a hospital-based educational experience for dental hygiene students and provides advocacy strategies for inclusion of dental hygienists within the hospital interdisciplinary team.

METHODS

The dental hygienist authors, both educators committed to evidence-based oral health care and the profession of dental hygiene, studied hospital health care and recognized a critical void in oral health care provision within that setting. They collaboratively developed and implemented a hospital-based rotation within the curriculum of a dental hygiene educational program and used advocacy skills to encourage hospital administrators to include a dental hygiene presence within hospital-based care teams.

CONCLUSIONS

Hospital-based dental hygiene practice, as part of interprofessional health care delivery, has the potential to improve patient well-being, shorten hospital stays, and provide fiscal savings for patients, institutions, and third party payers. Advocacy efforts can promote dental hygienists as members of hospital-based health care teams. Further research is needed to document: (1) patient outcomes resulting from optimal oral care provision in hospitals; (2) best ways to prepare dental hygienists for career opportunities within hospitals and other similar health care settings; and (3) most effective advocacy strategies to promote inclusion of dental hygienists within care teams.