Inadequate salivary flow and poor oral mucosal status in intubated intensive care unit patients

Impaired oral health: a required companion of bacterial aspiration pneumonia

Laryngotracheal aspiration has a widely-held reputation as a primary cause of lower respiratory infections, such as pneumonia, and is a major concern of care providers of the seriously ill orelderly frail patient. Laryngeal mechanical inefficiency resulting in aspiration into the lower respiratory tract, by itself, is not the cause of pneumonia. It is but one of several factors that must be present simultaneously for pneumonia to develop. Aspiration of oral and gastric contentsoccurs often in healthy people of all ages and without significant pulmonary consequences. Inthe seriously ill or elderly frail patient, higher concentrations of pathogens in the contents of theaspirate are the primary catalyst for pulmonary infection development if in an immunocompromised lower respiratory system. The oral cavity is a complex and ever changing eco-environment striving to maintain homogeneity among the numerous microbial communities inhabiting its surfaces. Poor maintenance of these surfaces to prevent infection can result inpathogenic changes to these microbial communities and, with subsequent proliferation, can altermicrobial communities in the tracheal and bronchial passages. Higher bacterial pathogen concentrations mixing with oral secretions, or with foods, when aspirated into an immunecompromised lower respiratory complex, may result in bacterial aspiration pneumonia development, or other respiratory or systemic diseases. A large volume of clinical evidence makes it clear that oral cleaning regimens, when used in caring for ill or frail patients in hospitals and long-term care facilities, drastically reduce the incidence of respiratory infection and death. The purpose of this narrative review is to examine oral health as a required causative companionin bacterial aspiration pneumonia development, and the effectiveness of oral infection control inthe prevention of this disease.

Ventilator-Associated Pneumonia Bundle of Care Training of Nursing Officers Using Simulation and Its Impact on Their Knowledge and Incidence of Ventilator-Associated Pneumonia: A Quasi-Experimental Study

The objective of this study was to assess the effectiveness of simulation-based training (SBT) of a ventilator-associated pneumonia (VAP) bundle of care on the knowledge and practice of nursing officers working in the pediatric intensive care unit (PICU) and its impact on the incidence of VAP. This study was a single-center, pre- and postsimulation-based educational interventional tool conducted in a six-bed PICU located in Western Rajasthan, India. Thirty nursing officers working in the PICU participated in the study. Baseline knowledge and practice regarding VAP bundle of care were assessed using a questionnaire and practice checklist. It was followed by 1:1 SBT of the VAP bundle of care following which all participants were immediately reassessed and then again at 3 months postintervention. The incidence of VAP (events/1,000 ventilation days) was subsequently compared both at 6 months pre- and postintervention. Thirty nursing officers participated in the study of which 63% were male. Baseline knowledge and practice increased significantly immediately after the VAP bundle of care training and then again at 3 months in comparison to preintervention testing (baseline 20.27 ± 4.51, immediate postintervention 26.0 ± 3.67, 3 months postintervention 23.97 ± 4.69). The incidence of VAP showed a declining trend from 46.1 to 36.5/1,000 ventilation days; however, this finding was not statistically significant ( p  = 0.22). The simulation-based teaching program significantly enhanced nursing officers' knowledge and practice toward utilization of a preventive VAP bundle of care. There was decay in knowledge with time indicating that repetitive sessions are required at regular intervals to sustain this effect.

Effectiveness of Swallowing and Oral Care Interventions on Oral Intake and Salivary Flow of Patients Following Endotracheal Extubation at a Tertiary Care Center: A Randomized Controlled Trial

Introduction

Endotracheal intubation and mechanical ventilation are the most frequently used life-sustaining interventions in critical care. Prolonged intubation can lead to post-extubation dysphagia, affecting the individual's nutritional level and communication ability. Thereupon, this study aims to assess the effectiveness of swallowing and oral care interventions in resuming oral intake and increasing salivary flow in post-extubation patients.

Methods

A randomized controlled trial was conducted in critical care units of a tertiary care setting, where 92 post-extubation patients who had undergone intubation for≥48 hours were enrolled. The intervention group received swallowing and oral interventions, including safe swallowing education (SSE), toothbrushing, salivary gland massage, oral cavity, and swallowing exercises. In contrast, the control group received standard oral care every 8th hour. Oral intake was assessed daily with the Functional Oral Intake Scale, and the salivary flow measurement was assessed with oral Schirmer's test on the 1st, 3rd, and 7th day after extubation.

Results

The baseline demographic and clinical characteristics showed that the groups were homogenous. The intervention group achieved total oral intake two days earlier than the control group. Findings also showed that the participants in the intervention group had a significant increase in salivary flow than in the control group on the 3rd and 7th days of the intervention.

Conclusion

Swallowing and oral care interventions help post-extubation patients resume early oral intake and increase salivary flow after prolonged intubation. Hence, it improves the patient's outcome toward a healthy life.

Development and evaluation of simulation-based scenario education program for professional oral hygiene care in intubated patient

PURPOSE

This study was conducted to develop a professional oral hygiene care (POHC) simulation education program for intubated patients and to evaluate the suitability of education by evaluating the performance confidence (PC), critical thinking disposition (CT), and learning satisfaction (LS) of dental hygiene students.

METHODS

This study developed a POHC simulation education program (theory, skill training, scenario education, and debriefing) for intubated patients through expert validation and consisted of a single-group pre- and postexperiment design. The subjects were 3rd and 4th year students at the Department of Dental Hygiene in Wonju City, and a total of 30 people were enrolled. The collected data were analyzed using the PASW Statistics version 23.0. The content validity test was measured by the CVI (Content validity index) value, and the PC, CT, and LS of the subjects before and after participating in the program were analyzed using a paired t-test. The significance level (α) was based on .05.

RESULTS

After the program, the PC improved from 4.29 ± 0.43 to 4.54 ± 0.44, and there was a significant difference (p = .004). CT improved from 3.73 ± 0.36 to 3.84 ± 0.36, but there was no significant difference (p = .062), and prudence improved from 4.21 ± 0.33 to 4.43 ± 0.27, and there was significant difference. (p = .001). LS increased from 4.66 ± 0.36 to 4.90 ± 0.16 after education, and there was a significant difference (p = .002).

CONCLUSION(S)

Simulation education program improved dental hygiene students' POHC performance confidence. Various scenarios will need to be developed in the future, and it is necessary to evaluate simulation education within the dental hygiene curriculum and identify areas for improvement.

COVID-19 hospitalized patients and oral changes: a case-control study

OBJECTIVES

To investigate the association between hospitalization for COVID-19 and oral changes, and to evaluate whether oral changes can indicate a higher risk of disease progression to death.

MATERIALS AND METHODS

This case-control study analyzed patients hospitalized (university hospital), including those in intensive care unit and clinical wards. The study group comprised 69 COVID-19 positive patients (PCR-test), while the control group included 43 COVID-19 negative patients. A dentist performed oral evaluations, and salivary samples were collected for calcium, phosphatase, and pH analysis. Sociodemographic data, hospitalization information, and hematological test results were collected from electronic-medical records. The presence of oral changes was assessed using chi-square tests, and the predicted risk of death was analyzed using binary logistic regression.

RESULTS

COVID-19 positive patients had a significantly higher prevalence of oral changes compared to COVID-19 negative patients. The presence of any oral changes in COVID-19 positive patients indicated a 13-fold higher risk of mortality. "Bleeding ulcers," "pressure ulcers," and "angular cheilitis" were significantly associated with hospitalization for COVID-19.

CONCLUSION

There may be an association between hospitalization for COVID-19 and the development of oral changes, including bleeding ulcers, pressure ulcers. and angular cheilitis. These oral changes may serve as potential indicator for disease progression an increased risk of death.

CLINICAL RELEVANCE

COVID-19 hospitalized patients have a higher prevalence of oral changes, which indicate an increased risk of mortality. Oral medicine staff should be included in multidisciplinary teams to detect and treat these oral changes promptly.

Relieving Perception of Thirst and Xerostomia in Patients with Palliative and End-of-life Care Needs: A Rapid Review

CONTEXT

Thirst and dry mouth are interlinked symptoms that frequently cause significant distress for patients with life-limiting conditions.

OBJECTIVES

The objective of this rapid review was to identify and synthesize effective interventions that relieve perceptions of thirst and dry mouth of patients with palliative care and end-of-life care needs.

METHODS

Eligible studies were undertaken in clinical settings, with patients experiencing thirst-related distress and/or dry mouth. This review of peer-reviewed literature was conducted following aspects of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. The main outcomes of interest were: 1) efficacy of thirst and dry mouth interventions for patient, and 2) patient, caregiver, and staff acceptability and satisfaction of the interventions. Scientific journal articles were retrieved through searches in electronic databases of MEDLINE (Ovid), CINAHL (EBSCO), and AgeLine (EBSCO).

RESULTS

Eleven studies were included for analysis and synthesis of the results. Most studies either focused on a dry mouth intervention or reported dry mouth outcomes within a broader thirst intervention (n = 9/11 studies). Standard oral care was the common intervention type (n = 5/11). All but one dry mouth intervention reported statistical improvement in outcomes of interest. All studies that reported on thirst were conducted in an Intensive Care Unit (ICU) setting (n = 4/4). No studies specifically addressed thirst in patients in specialist palliative care settings.

CONCLUSION

Evidence from this review suggests that thirst interventions established within the ICU setting may prove effective for treatment of terminally ill patients receiving specialist palliative care.

Efficacy and Safety of Oral Hydration 1 Hour After Extubation of Patients Undergoing Cardiac Surgery: A Randomized Controlled Trial

BACKGROUND

Thirst is one of the most common and uncomfortable symptoms in patients after cardiac surgery. The postextubation time for early oral hydration (EOH) remains unclear, and there is a lack of studies on its safety and effectiveness.

OBJECTIVE

The aim of this study was to investigate the effects of oral hydration 1 hour after extubation on thirst, salivary pH, salivary flow, oral mucosa, halitosis, gastrointestinal adverse reactions, aspiration pneumonia, and satisfaction in patients undergoing cardiac surgery.

METHODS

Eighty-four patients who underwent cardiac surgery were randomly assigned into 2 groups, for either conventional oral hydration (COH) or EOH. The EOH group drank 30 mL of warm water 1 hour post extubation and thereafter 50 mL hourly for 4 hours. The COH group had nil per os for 4 hours after extubation. If no dysphagia was evident after 4 hours, the patients were instructed to slowly drink water. Thirst intensity was evaluated every hour before the intervention. Nausea and vomiting were recorded after drinking water. The salivary pH, unstimulated salivary flow rate, oral odor, and oral mucosal moisture were evaluated at 1 hour post extubation, immediately before the intervention, and at 4 hour post intervention. Aspiration pneumonia data were collected within 72 hours post intervention. Satisfaction was assessed before leaving the intensive care unit.

RESULTS

The scores for thirst (3.38 ± 1.04; F = 306.21, P < .001), oral mucosa (2.03 ± 0.74; P < .001), and halitosis (2.77 ± 0.63; P < .001) in the EOH group were significantly lower than those in the COH group. The EOH group had significantly higher salivary pH (6.44 ± 1.06; P < .001), unstimulated salivary flow rates (0.18 ± 0.08; P < .001), and patient satisfaction (4.28 ± 0.45; P < .001) than the COH group. Nausea and vomiting did not differ significantly between groups (P = .60). Aspiration pneumonia was not observed in either group.

CONCLUSIONS

Oral hydration 1 hour after extubation significantly alleviated thirst and stabilized the oral environment without gastrointestinal adverse reactions or aspiration pneumonia, and with increased patient satisfaction.

Perioperative Oral Management Prevents Complications of Heart Valve Surgery

OBJECTIVES

The effect of perioperative oral management on the prevention of postoperative complications remains unclear in cardiac surgery. Exploratory factor analysis was performed to examine whether a lack of perioperative oral management was associated with postoperative complications of heart valve surgery.

MATERIALS AND METHODS

We retrospectively enrolled 365 patients who underwent heart valve surgery between April 2010 and March 2019. We extracted data on patient characteristics and set postoperative pneumonia and postoperative bloodstream infection as outcomes. A logistic regression analyses were performed to examine the effect of factors on the incidence of postoperative complications.

RESULTS

Significant risk factors for postoperative pneumonia included dialysis, long operative time, and long-term intubation. Similarly, risk factors for postoperative bloodstream infection were long-term intubation and lack of perioperative oral management. Subsequently, we identified the risk factors for long-term intubation, which were common to both complications, and found they were emergency status, combined valvular disease, long operative time, and lack of perioperative oral management.

CONCLUSIONS

We demonstrated that a lack of perioperative oral management could be a risk factor for postoperative bloodstream infection and long-term intubation in heart valve surgery. The results suggest that perioperative oral management is effective in preventing postoperative complications of heart valve surgery.

Oral lesions and saliva alterations of COVID-19 patients in an intensive care unit: A retrospective study

Aim

To detect the type and frequency of oral lesions and clinical conditions suggestive of saliva alterations in COVID‐19 patients in an intensive care unit (ICU), as well as to describe the patient´s management in each case

Methods

Information about oral conditions and mechanical ventilation was collected from oral medicine records of COVID‐19 patients in an ICU (n = 519)

Results

From the total collected, 472 patients (90.9%) were examined by the oral medicine staff. In 242/472 patients (51.3%), alterations in the oral cavity were noted. The most frequent changes were mechanical trauma (18.1%, derived mainly from intubation), vascular/coagulation disturbances (24.1%, petechiae, bruises, varicoses, and oral bleeding), and saliva alterations (24.4%, dry mouth, and sialorrhea). Infectious lesions were mentioned in the oral medicine records (16.9%), most associated with a viral infection (15.7%), mainly herpesvirus. Improved oral change protocols included oral hygiene, use of specific medications, and laser therapy

Conclusion

COVID‐19 patients in the ICU often showed dryness in the oral and mucosa oral lesions related to vascular/coagulation disturbances, and mechanical trauma derived from orotracheal tube. An oral medicine staff must be aligned with the ICU multidisciplinary team to manage COVID‐19 patients, as well as to establish diagnoses and oral cavity treatments.

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.

Detection of nosocomial pneumonia pathogens using a fluorescence-based device

BACKGROUND

Early detection of nosocomial pneumonia pathogens is a significant factor in hospital-acquired pneumonia care. This study aimed to determine the autofluorescence properties of five nosocomial pneumonia pathogens using a fluorescence-based device and to establish evidence for clinical guidelines.

METHODS

The following bacterial strains were assessed: Acinetobacter baumannii (AB), Escherichia coli (EC), Enterococcus faecalis (EF), Klebsiella pneumoniae (KP), and Staphylococcus aureus (SA). The bacteria were cultured separately on tryptic soy agar at 37°C under aerobic conditions for 168 h. Fluorescence photographs of each species were captured every 24 h using a fluorescence-based device with fixed camera settings. The images were analyzed by measuring the red and green values (R/G ratio) at a central point in each colony, and the R/G ratios were analyzed using the Kruskal-Wallis non-parametric test.

RESULTS

KP and SA showed red fluorescence with their R/G values, which were significantly higher than those of the other strains (p < 0.001). In particular, the R/G ratio of KP increased steadily until 72 h of incubation, peaking at 3.65. In addition, AB and EC showed orange fluorescence with higher red ratios than green ratios. EF and SA showed green fluorescence all through 168 h of incubation, with R/G values less than 1.0.

CONCLUSIONS

Nosocomial pneumonia pathogens can be identified and classified via bacterial autofluorescence emission. It is possible to develop a rapid and easy-to-use identification technology based on bacterial autofluorescence for clinical applications.

Thirst in patients admitted to intensive care units: an observational study

Background

Despite various studies reporting a high prevalence, reaching 71%, the sensation of thirst in intensive care unit (ICU) patients, its prevention, detection, and management, is not well known nor considered. Limited research has examined the causes of thirst in ICU patients, while it has been examined in other patient populations.

Aim

To determine the incidence and intensity of thirst in patients admitted to ICU and its association with airway devices (endotracheal tube, tracheostomy, oxygen mask), airway humidification, patients’ characteristics, and therapy (serum sodium concentration, hematocrit, fluid balance, possibility of oral hydration, and dosage of diuretics).

Methods

Patients were interviewed daily to report the presence of thirst and rate its intensity on a Numeric Rating Scale (NRS) from 0 (no thirst) –10 (intolerable thirst). Other data were obtained through direct evaluation or by consulting medical records. Patients admitted to three ICUs from May to August 2014 in a university hospital in Italy were included.

Results

A total of 220 Patients were enrolled. Thirst was found in 76.1% of patients’ observations, with a mean thirst score of 5.37. Thirst intensity was predicted by high doses of diuretics (> 100 mg/die), increasing serum sodium concentration, absence of oral hydration and the presence of xerostomia. Thirst was associated with the use of humidified Venturi mask.

Conclusions

Thirst is highly prevalent among patients in this population of intensive care patients. It would be desirable to evaluate this stressor at least daily, to eliminate or relieve this sensation.

Problems with identifying and distinguishing salivary streptococci: a multi-instrumental approach

Aim: The purpose of this study was to create an alternative protocol for the DNA-based identification of salivary microbiota focused on the distinguishing of Streptococcus species. Materials & methods: Salivary bacteria were identified using 16S rDNA sequencing and proteins and lipids profiling using MALDI-TOF/MS as well as FTIR analysis. Results: Most of the isolates belonged to streptococci - mostly the salivarious group indistinguishable by the molecular technique. In turn, MALDI analysis allowed for their fast and reliable classification. Although FTIR spectroscopy demonstrated the correct species classification, the spectra interpretation was time consuming and complicated. Conclusion: MALDI-TOF/MS demonstrated the biggest effectiveness in the identification and discrimination between the salivary streptococci, which could be easily incorporated in the workflow of routine microbiological laboratories.

Effect of oral chlorhexidine de-adoption and implementation of an oral care bundle on mortality for mechanically ventilated patients in the intensive care unit (CHORAL): a multi-center stepped wedge cluster-randomized controlled trial

Purpose

Oral chlorhexidine is used widely for mechanically ventilated patients to prevent pneumonia, but recent studies show an association with excess mortality. We examined whether de-adoption of chlorhexidine and parallel implementation of a standardized oral care bundle reduces intensive care unit (ICU) mortality in mechanically ventilated patients.

Methods

A stepped wedge cluster-randomized controlled trial with concurrent process evaluation in 6 ICUs in Toronto, Canada. Clusters were randomized to de-adopt chlorhexidine and implement a standardized oral care bundle at 2-month intervals. The primary outcome was ICU mortality. Secondary outcomes were time to infection-related ventilator-associated complications (IVACs), oral procedural pain and oral health dysfunction. An exploratory post hoc analysis examined time to extubation in survivors.

Results

A total of 3260 patients were enrolled; 1560 control, 1700 intervention. ICU mortality for the intervention and control periods were 399 (23.5%) and 330 (21.2%), respectively (adjusted odds ratio [aOR], 1.13; 95% confidence interval [CI] 0.82 to 1.54; P = 0.46). Time to IVACs (adjusted hazard ratio [aHR], 1.06; 95% CI 0.44 to 2.57; P = 0.90), time to extubation (aHR 1.03; 95% CI 0.85 to 1.23; P = 0.79) (survivors) and oral procedural pain (aOR, 0.62; 95% CI 0.34 to 1.10; P = 0.10) were similar between control and intervention periods. However, oral health dysfunction scores (− 0.96; 95% CI − 1.75 to − 0.17; P = 0.02) improved in the intervention period.

Conclusion

Among mechanically ventilated ICU patients, no benefit was observed for de-adoption of chlorhexidine and implementation of an oral care bundle on ICU mortality, IVACs, oral procedural pain, or time to extubation. The intervention may improve oral health.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00134-021-06475-2.

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.

Comparison of the Effect of Breast Milk and Sodium Bicarbonate Solution for Oral Care in Infants with Tracheal Intubation After Cardiothoracic Surgery

Background: This study aimed to explore the effect of breast milk and sodium bicarbonate solution used in oral care of infants with tracheal intubation after cardiothoracic surgery. Methods: A randomized clinical controlled trial was conducted in a provincial hospital in China. Fifty infantile patients were randomly divided into two groups: the patients in the study group (n = 25) used breast milk for oral care and the patients in the control group (n = 25) used sodium bicarbonate solution for oral care. The relevant clinical data were recorded, including the mechanical ventilation duration, length of intensive care unit (ICU) stay, length of hospital stay, and complications. Results: The length of ICU stay, length of hospital stay, and duration of mechanical ventilation were shorter in the study group, but the difference was not statistically significant (p > 0.05). However, the incidence of thrush and ventilator-associated pulmonary infection in the study group was significantly lower than that in the control group (p < 0.05). Conclusion: The use of breast milk for oral care has a positive effect on the prevention of thrush and ventilator-associated pulmonary infection in infants with tracheal intubation after cardiothoracic surgery.

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.

Combination of toothbrushing and chlorhexidine compared with exclusive use of chlorhexidine to reduce the risk of ventilator-associated pneumonia: A systematic review with meta-analysis

This study aimed to compare the effectiveness of 0.12% chlorhexidine alone and 0.12% chlorhexidine in combination with toothbrushing to prevent ventilator-associated pneumonia (VAP) in mechanically ventilated patients. The Embase, Latin American and Caribbean Health Science Literature, PubMed, Scientific Electronic Library Online, Scopus, LIVIVO, Web of Science, Cochrane Library, OpenThesis, and Open Access Thesis and Dissertations databases were used. Only randomized controlled trials without restrictions on the year or language of publication were included. Two reviewers assessed the risk of bias using the Joanna Briggs Institute Critical Appraisal Tool. A meta-analysis using a random-effects model estimated the combined relative risk (RR). The Grading of Recommendations, Assessment, Development and Evaluations approach was used to assess the certainty of the evidence. Initially, 2,337 studies were identified, of which 4 were considered in the systematic review and 3 in the meta-analysis (total sample: 796 patients). The studies were published between 2009 and 2017. All eligible studies had a low risk of bias. The meta-analysis revealed that the risk of VAP was 24% lower in patients receiving chlorhexidine combined with toothbrushing than in those receiving chlorhexidine alone (RR: 0.76; 95% confidence interval: 0.55-1.06), with moderate certainty of evidence and without statistical significance. In conclusion, considering the limitations of this study, a standard protocol for the prevention of VAP is not yet recommended. More studies with larger sample sizes are needed to draw strong conclusions. However, considering that toothbrushing is a simple intervention, it should be a common practice in mechanically ventilated patients, especially among patients with coronavirus disease.

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.

Recall of pain and discomfort during oral procedures experienced by intubated critically ill patients in the intensive care unit: A qualitative elicitation study

Background: Intubated and mechanically ventilated patients in the intensive care unit (ICU) may experience pain during routine oral procedures such as oral suctioning and tooth brushing. Despite the importance of pain prevention and management, little is known about patients’ experiences of procedural oral pain.

Aims: The aim of this study was to explore patients’ recollections and recommendations for pain and discomfort during routine oral procedures.

Methods: A qualitative descriptive design was used. Adult patients were recruited from a mixed medical–surgical–trauma ICU in an academic hospital in Toronto, Canada. Participants were interviewed using object elicitation methods within 7 days of discharge from the ICU. Data were analyzed using directed content analysis methods.

Results: We recruited 33 participants who were primarily male (23, 70%), with an average age of 54 (SD = 18) years, admitted with a medical (13, 39%), trauma (11, 33%), or surgical (9, 27%) diagnosis and dentate (27, 82%). Most participants described oral procedures as painful, discomforting, and emotionally distressing. Identified sources of pain included dry, inflamed oral tissues and procedural technique. Procedural pain behaviors were perceived to be frequently misinterpreted by clinicians as agitation, with consequences including physical restraint and unrelieved suffering. Participants advocated for greater frequency of oral care to prevent oral health deterioration, anticipatory procedural guidance, and structured pain assessment to mitigate the dehumanizing experience of unmanaged pain.

Conclusions: Patients described routine oral care procedures as painful and recalled suboptimal management of such pain. Procedural oral pain is an important target for practice improvement.

Oral Microbiome and SARS-CoV-2: Beware of Lung Co-infection

The new coronavirus SARS-CoV-2, the cause of COVID-19, has become a public health emergency of global concern. Like the SARS and influenza pandemics, there have been a large number of cases coinfected with other viruses, fungi, and bacteria, some of which originate from the oral cavity. Capnocytophaga, Veillonella, and other oral opportunistic pathogens were found in the BALF of the COVID-19 patients by mNGS. Risk factors such as poor oral hygiene, cough, increased inhalation under normal or abnormal conditions, and mechanical ventilation provide a pathway for oral microorganisms to enter the lower respiratory tract and thus cause respiratory disease. Lung hypoxia, typical symptoms of COVID-19, would favor the growth of anaerobes and facultative anaerobes originating from the oral microbiota. SARS-CoV-2 may aggravate lung disease by interacting with the lung or oral microbiota via mechanisms involving changes in cytokines, T cell responses, and the effects of host conditions such as aging and the oral microbiome changes due to systemic diseases. Because the oral microbiome is closely associated with SARS-CoV-2 co-infections in the lungs, effective oral health care measures are necessary to reduce these infections, especially in severe COVID-19 patients. We hope this review will draw attention from both the scientific and clinical communities on the role of the oral microbiome in the current global pandemic.

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.

Effects of a swallowing and oral care intervention for patients following endotracheal extubation: a pre- and post-intervention study

Background

For patients who survive a critical illness and have their oral endotracheal tube removed, dysphagia is highly prevalent, and without intervention, it may persist far beyond hospital discharge. This pre- and post-intervention study with historical controls tested the effects of a swallowing and oral care (SOC) intervention on patients’ time to resume oral intake and salivary flow following endotracheal extubation.

Methods

The sample comprised intensive care unit patients (≥ 50 years) successfully extubated after ≥ 48 h endotracheal intubation. Participants who received usual care (controls, n = 117) were recruited before 2015, and those who received usual care plus the intervention (n = 54) were enrolled after 2015. After extubation, all participants were assessed by a blinded nurse for daily intake status (21 days) and whole-mouth unstimulated salivary flow (2, 7, 14 days). The intervention group received the nurse-administered SOC intervention, comprising toothbrushing/salivary gland massage, oral motor exercise, and safe-swallowing education daily for 14 days or until hospital discharge.

Results

The intervention group received 8.3 ± 4.2 days of SOC intervention, taking 15.4 min daily with no reported adverse event (coughing, wet voice, or decreased oxygen saturation) during and immediately after intervention. Participants who received the intervention were significantly more likely than controls to resume total oral intake after extubation (aHR 1.77, 95% CI 1.08–2.91). Stratified by age group, older participants (≥ 65 years) in the SOC group were 2.47-fold more likely than their younger counterparts to resume total oral intake (aHR 2.47, 95% CI 1.31–4.67). The SOC group also had significantly higher salivary flows 14 days following extubation (β = 0.67, 95% CI 0.29–1.06).

Conclusions

The nurse-administered SOC is safe and effective, with greater odds of patients’ resuming total oral intake and increased salivary flows 14 days following endotracheal extubation. Age matters with SOC; it more effectively helped participants ≥ 65 years old resume total oral intake postextubation.

Trial registration

NCT02334774, registered on January 08, 2015

Protocol for a multi-centered, stepped wedge, cluster randomized controlled trial of the de-adoption of oral chlorhexidine prophylaxis and implementation of an oral care bundle for mechanically ventilated critically ill patients: the CHORAL study

BACKGROUND

Routine application of chlorhexidine oral rinse is recommended to reduce risk of ventilator-associated pneumonia (VAP) in mechanically ventilated patients. Recent reappraisal of the evidence from two meta-analyses suggests chlorhexidine may cause excess mortality in non-cardiac surgery patients and does not reduce VAP. Mechanisms for possible excess mortality are unclear. The CHORAL study will evaluate the impact of de-adopting chlorhexidine and implementing an oral care bundle (excluding chlorhexidine) on mortality, infection-related ventilator-associated complications (IVACs), and oral health status.

METHODS

The CHORAL study is a stepped wedge, cluster randomized controlled trial in six academic intensive care units (ICUs) in Toronto, Canada. Clusters (ICU) will be randomly allocated to six sequential steps over a 14-month period to de-adopt oral chlorhexidine and implement a standardized oral care bundle (oral assessment, tooth brushing, moisturization, and secretion removal). On study commencement, all clusters begin with a control period in which the standard of care is oral chlorhexidine. Clusters then begin crossover from control to intervention every 2 months according to the randomization schedule. Participants include all mechanically ventilated adults eligible to receive the standardized oral care bundle. The primary outcome is ICU mortality; secondary outcomes are IVACs and oral health status. We will determine demographics, antibiotic usage, mortality, and IVAC rates from a validated local ICU clinical registry. With six clusters and 50 ventilated patients on average each month per cluster, we estimate that 4200 patients provide 80% power after accounting for intracluster correlation to detect an absolute reduction in mortality of 5.5%. We will analyze our primary outcome of mortality using a generalized linear mixed model adjusting for time to account for secular trends. We will conduct a process evaluation to determine intervention fidelity and to inform interpretation of the trial results.

DISCUSSION

The CHORAL study will inform understanding of the effectiveness of de-adoption of oral chlorhexidine and implementation of a standardized oral care bundle for decreasing ICU mortality and IVAC rates while improving oral health status. Our process evaluation will inform clinicians and decision makers about intervention delivery to support future de-adoption if justified by trial results.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03382730 . Registered on December 26, 2017.

Oropharyngeal Bacterial Colonization after Chlorhexidine Mouthwash in Mechanically Ventilated Critically Ill Patients

WHAT WE ALREADY KNOW ABOUT THIS TOPIC

WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Oropharyngeal care with chlorhexidine to prevent ventilator-associated pneumonia is currently questioned, and exhaustive microbiologic data assessing its efficacy are lacking. The authors therefore aimed to study the effect of chlorhexidine mouthwash on oropharyngeal bacterial growth, to determine chlorhexidine susceptibility of these bacteria, and to measure chlorhexidine salivary concentration after an oropharyngeal care.

METHODS

This observational, prospective, single-center study enrolled 30 critically ill patients under mechanical ventilation for over 48 h. Oropharyngeal contamination was assessed by swabbing the gingivobuccal sulcus immediately before applying 0.12% chlorhexidine with soaked swabs, and subsequently at 15, 60, 120, 240, and 360 min after. Bacterial growth and identification were performed, and chlorhexidine minimal inhibitory concentration of recovered pathogens was determined. Saliva was collected in 10 patients, at every timepoint, with an additional timepoint after 30 min, to measure chlorhexidine concentration.

RESULTS

Two hundred fifty bacterial samples were analyzed and identified 48 pathogens including Streptococci (27.1%) and Enterobacteriaceae (20.8%). Oropharyngeal contamination before chlorhexidine mouthwash ranged from 10 to 10 colony-forming units (CFU)/ml in the 30 patients (median contamination level: 2.5·10 CFU/ml), and remained between 8·10 (lowest) and 3·10 CFU/ml (highest count) after chlorhexidine exposure. These bacterial counts did not decrease overtime after chlorhexidine mouthwash (each minute increase in time resulted in a multiplication of bacterial count by a coefficient of 1.001, P = 0.83). Viridans group streptococci isolates had the lowest chlorhexidine minimal inhibitory concentration (4 [4 to 8] mg/l); Enterobacteriaceae isolates had the highest ones (32 [16 to 32] mg/l). Chlorhexidine salivary concentration rapidly decreased, reaching 7.6 [1.8 to 31] mg/l as early as 60 min after mouthwash.

CONCLUSIONS

Chlorhexidine oropharyngeal care does not seem to reduce bacterial oropharyngeal colonization in critically ill ventilated patients. Variable chlorhexidine minimal inhibitory concentrations along with low chlorhexidine salivary concentrations after mouthwash could explain this ineffectiveness, and thus question the use of chlorhexidine for ventilator-associated pneumonia prevention.

Exploration of difficulty accessing the mouths of intubated and mechanically ventilated adults for oral care: A video and photographic elicitation study

AIM

To explore descriptors of difficulty accessing the mouths of intubated and mechanically ventilated adults for oral care, consequences, modifiable antecedents and recommendations for improving care delivery.

BACKGROUND

Nurses report oral access and care delivery difficulty in most mechanically ventilated patients.

DESIGN

A prospective qualitative descriptive design.

METHODS

Data were collected using video and photographic elicitation interviews focused on delivery of oral care. Directed content analysis was used to explore descriptive categories. Reporting used the SRQR guidelines.

SETTING AND PARTICIPANTS

A university-affiliated hospital in Toronto, Canada. Participants included clinicians experienced in accessing the oral space of adults representing nursing, medicine, dentistry and allied health professionals.

FINDINGS

We recruited 18 participants; 9 representing critical care and 9 other specialties frequently accessing the mouth, that is dentistry. Descriptors for observed difficulty accessing the oral cavity were "oral crowding with tubes" and "aversive patient responses", which were considered to result in insufficient oral care. Participants perceived aversive patient responses (e.g. biting, turning head side to side, gagging, coughing) as a consequence of forced introduction of instruments inside a crowded mouth. A key finding identified by participants was the observation of substantial procedural pain during oral care interventions. Potentially modifiable antecedents to difficult oral care delivery identified were procedural pain, oral health deterioration (e.g. xerostomia) and lack of interprofessional team problem-solving. Recommendations to address these antecedents included patient preparation for oral care through verbal and nonverbal cueing, pharmacological and nonpharmacological strategies, and ICU interprofessional education.

CONCLUSIONS

Oral care in mechanically ventilated adults is complex and painful. Visual research methods offer important advantages for oral care exploration including its ability to reveal less visible aspects of the nurse-patient encounter, thereby enabling novel insights and care.

RELEVANCE FOR CLINICAL PRACTICE

Interprofessional education and training in oral health and care interventions tailored to mechanically ventilated patients are recommended.

Periodontitis and Periodontopathogens in Individuals Hospitalized in the Intensive Care Unit: A Case-Control Study

The aim of the present study was to compare periodontal conditions between intensive care unit (ICU) in-patients and non-ICU patients through clinical and microbiological periodontal parameters. This case-control study included 88 individuals hospitalized in ICU and 176 non-hospitalized controls. All individuals underwent a complete periodontal examination and microbiological sampling. The total bacterial load and counts of Porphyromonas gingivalis, Treponema denticola and Aggregatibacter actinomycetemcomitans were evaluated using qPCR. Data were analyzed through the Chi-square, Fisher exact, and t-Student tests, and the Spearman correlation, as appropriate. The prevalence of periodontitis was 39.7% among controls and 59.0% among ICU in-patients (OR=2.18; p=0.002). ICU in-patients had a significantly higher occurrence of cardiovascular disease (p=0.002; OR=2.20) and history of periodontal disease (p=0.031; OR=1.92) than controls. Bacterial counts of A. actinomycetemcomitans, T. denticola and P. gingivalis were significantly higher in ICU in-patients with periodontitis than in controls. The correlation between periodontal parameters and microbiological findings among cases and controls showed a significant and positive correlation between: total bacteria load and % of sites with probing depth (PD) ≥ 4 mm (cases: r=0.22 and controls: r=0.13) and P. gingivalis and % sites with bleeding on probing (BOP) (cases: r=0.22 and controls: r=0.23). Thus, ICU in-patients presented a higher prevalence of periodontitis and worse periodontal condition (higher mean plaque index, BOP, clinical attachment level ≥3 mm, and sites with PD 4 to 6 mm).

The Human Salivary Antimicrobial Peptide Profile according to the Oral Microbiota in Health, Periodontitis and Smoking

Antimicrobial peptides (AMPs) are a diverse family of peptides that defend the mucosal surfaces of the oral cavity and other locations. Many AMPs have multiple functions and properties that influence aspects of innate defense and colonization by microorganisms. The human oral cavity is home to the second-most diverse microbiome, and the health of the mouth is influenced by the presence of these bacteria as well as by extrinsic factors such as periodontitis and smoking. This study hypothesized that the AMP profile is different in the presence of extrinsic factors and that this would also be reflected in the bacteria present. The AMP profile was analyzed by quantitative selected-reaction-monitoring mass spectrometry analysis and 40 bacterial species were quantified by DNA-DNA hybridization in saliva donated by 41 individuals. Periodontal status was assessed through dental examination and smoking status through medical charting. Periodontal health (in nonsmokers) was associated with a higher abundance of ribonuclease 7, protachykinin 1, β-defensin 128, lipocalin 1, bactericidal permeability-increasing protein fold-containing family B member 3, and bone-marrow proteoglycan. Nonsmoking periodontal disease was associated with an abundance of neutrophil defensin 1 and cathelicidin. However, 7 AMPs were overabundant in periodontal disease in smokers: adrenomedullin, eosinophil peroxidase, 3 different histones, myeloperoxidase, and neutrophil defensin 1. There were no differentially abundant AMPs in smokers versus nonsmokers with periodontal health. Correlation network inference of healthy nonsmokers, healthy smokers, nonsmoking periodontitis, or smoking periodontitis donors demonstrated very different networks growing in complexity with increasing numbers of stressors. The study highlights the importance of the interaction between the oral cavity and its resident microbiota and how this may be influenced by periodontal disease and smoking.

Validation of The Critical-care Pain Observation Tool (CPOT) for the detection of oral-pharyngeal pain in critically ill adults

OBJECTIVE

Mechanically ventilated patients experience pain at rest and during daily care procedures. Our objective was to test the reliability and validity of the Critical-Care Pain Observation Tool (CPOT) to detect oral-pharyngeal pain in intubated and tracheostomised adults during routine oral care procedures.

MATERIALS AND METHODS

Two trained research team members independently observed patients during two non-painful (rest and gentle touch) and three potentially painful (oral suctioning, tooth brushing, and swabbing with a sponge toothette) procedures. Conscious patients were asked if they experienced pain during each procedure (yes/no) and to rate their pain intensity on a 0 to 10 numeric rating scale.

RESULTS

A total of 98 patients, primarily intubated (92.9%) and male (63.3%) participated. Criterion validation was supported by patient self-report of pain during tooth brushing (AUC=.80; P<0.5) and oral suction (AUC=.72; P<0.3) but not for oral swabbing (AUC=.68; P=0.16). Discriminative validation was demonstrated for all oral care procedures compared to rest (P<.001). Intra-class correlation coefficients between raters ranged from .78 to .91 (P<.001) for total CPOT scores, indicating excellent inter-rater reliability.

CONCLUSIONS

The CPOT is reliable and valid for the detection of oral-pharyngeal pain during oral care procedures indicated as painful by critically ill adults.

Changes in bacterial number at different sites of oral cavity during perioperative oral care management in gastrointestinal cancer patients: preliminary study

OBJECTIVE

The objective of this study was to clarify differences in bacterial accumulation between gastrointestinal cancer patients who underwent severely invasive surgery and those who underwent minimally invasive surgery.

MATERIAL AND METHODS

We performed a preliminary investigation of gastrointestinal cancer patients who were treated at the Department of Surgery, Takarazuka Municipal Hospital, from 2015 to 2017 (n=71; 42 laparoscopic surgery, 29 open surgery) to determine changes in bacterial numbers at different sites of the oral cavity (tongue dorsum, gingiva of upper anterior teeth, palatoglossal arch), as well as mouth dryness and tongue coating indices. Specifically, patients received professional tooth cleaning (PTC), scaling, tongue cleaning, and self-care instruction regarding tooth brushing from a dental hygienist a day before the operation. Professional oral health care was also performed by a dental hygienist two and seven days after surgery. Oral bacteria numbers were determined using a bacterial counter with a dielectrophoretic impedance measurement method.

RESULTS

The number of bacteria at all three examined sites were significantly higher in the open surgery group when compared to the laparoscopic surgery group on the second postoperative day. Relevantly, bacterial count in samples from the gingiva of the upper anterior teeth remained greater seven days after the operation in patients who underwent open surgery. Furthermore, the dry mouth index level was higher in the open surgery group when compared to the laparoscopic surgery group on postoperative days 2 and 7.

CONCLUSIONS

Even with regular oral health care, bacterial numbers remained high in the upper incisor tooth gingiva in gastrointestinal cancer patients who received open surgery. Additional procedures are likely needed to effectively reduce the number of bacteria in the gingival area associated with the upper anterior teeth.

Prevalence and predictors of difficulty accessing the mouths of intubated critically ill adults to deliver oral care: An observational study

BACKGROUND

Oral care of intubated patients is essential to the prevention of infection and patient discomfort. However, barriers to oral access and delivery of oral care have received little attention.

OBJECTIVE

To determine prevalence and predictors of oral access difficulty.

DESIGN

A prospective, observational, multi-center study.

SETTINGS

Four intensive care units in Toronto, Canada.

PARTICIPANTS

Adult patients orally intubated for ≥48 h.

METHODS

We screened consecutive admissions once a week to identify eligible participants. We observed each patient and asked the patient's nurse about presence or absence of difficulty accessing the mouth to deliver oral care across three categories: (1) visualizing inside the mouth; (2) obtaining patient cooperation, or (3) inserting instruments for delivery of oral care. We asked nurses to identify presence of patient behaviors contributing to oral access difficulty and perceived level of difficulty on a Likert response scale. We examined patient and treatment characteristics associated with extreme difficulty (i.e., difficulty in all 3 categories) using a generalized estimating equation regression model.

RESULTS

A total of 428 patients were observed, 58% admitted with a medical diagnosis. More than half (57%) had ≥2 oral devices up to maximum of 4. Oral care difficulty was identified in 83% of patients and rated as moderate to high for 217 (51%). Difficulty concerned visibility (74%), patient cooperation (55%), and space to insert instruments (53%). Patient behaviors contributing difficulty included coughing/gagging (60%), mouth closing (49%), biting (45%) and localizing (27%) during care. Variables associated with extreme difficulty included neurological (OR 1.92, 95% CI 1.42-2.60) or trauma admission (OR 1.83, 95% CI 1.16-2.89), lack of pain assessment or treatment in the 4 h prior to oral care (OR 1.43, 95% CI 1.14-1.80), more oral devices (OR 1.40, 95% CI 1.05-1.87), and duration of intubation (OR 1.05, 95% CI 1.01-1.10). Absence of documented agitation in the 4 h prior to oral care was associated with less difficulty (OR 0.68, 95% CI 0.54-0.86).

CONCLUSIONS

Oral care is complex and difficulties are experienced in a vast majority of intubated patients. Some difficulties are amenable to correction such as pain management.

Bedside screen for oral cavity structure, salivary flow, and vocal production over the 14days following endotracheal extubation

PURPOSE

To describe the sequelae of oral endotracheal intubation by evaluating prevalence rates of structural injury, hyposalivation, and impaired vocal production over 14days following extubation.

MATERIALS AND METHODS

Consecutive adults (≥20years, N=114) with prolonged (≥48h) endotracheal intubation were enrolled from medical intensive care units at a university hospital. Participants were assessed by trained nurses at 2, 7, and 14days after extubation, using a standardized bedside screening protocol.

RESULTS

Within 48-hour postextubation, structural injuries were common, with 51% having restricted mouth opening. Unstimulated salivary flow was reduced in 43%. For vocal production, 51% had inadequate breathing support for phonation, dysphonia was common (94% had hoarseness and 36% showed reduced efficiency of vocal fold closure), and >40% had impaired articulatory precision. By 14days postextubation, recovery was noted in most conditions, but reduced efficiency of vocal fold closure persisted. Restricted mouth opening (39%) and reduced salivary flow (34%) remained highly prevalent.

CONCLUSIONS

After extubation, restricted mouth opening, reduced salivary flow, and dysphonia were common and prolonged in recovery. Reduced efficiency of vocal cord closure persisted at 14days postextubation. The extent and duration of these sequelae remind clinicians to screen for them up to 2weeks after extubation.

Respiratory pathogen colonization of dental plaque, the lower airways, and endotracheal tube biofilms during mechanical ventilation

PURPOSE

In mechanically ventilated patients, the endotracheal tube is an essential interface between the patient and ventilator, but inadvertently, it also facilitates the development of ventilator-associated pneumonia (VAP) by subverting pulmonary host defenses. A number of investigations suggest that bacteria colonizing the oral cavity may be important in the etiology of VAP. The present study evaluated microbial changes that occurred in dental plaque and lower airways of 107 critically ill mechanically ventilated patients.

MATERIALS AND METHODS

Dental plaque and lower airways fluid was collected during the course of mechanical ventilation, with additional samples of dental plaque obtained during the entirety of patients' hospital stay.

RESULTS

A "microbial shift" occurred in dental plaque, with colonization by potential VAP pathogens, namely, Staphylococcus aureus and Pseudomonas aeruginosa in 35 patients. Post-extubation analyses revealed that 70% and 55% of patients whose dental plaque included S aureus and P aeruginosa, respectively, reverted back to having a predominantly normal oral microbiota. Respiratory pathogens were also isolated from the lower airways and within the endotracheal tube biofilms.

CONCLUSIONS

To the best of our knowledge, this is the largest study to date exploring oral microbial changes during both mechanical ventilation and after recovery from critical illness. Based on these findings, it was apparent that during mechanical ventilation, dental plaque represents a source of potential VAP pathogens.

Ventilator-associated pneumonia risk decreased by use of oral moisture gel in oral health care

Although oral health care has a preventive effect against ventilator-associated pneumonia (VAP), the most effective method of oral health care in this respect remains to be established. The objective of this single-center, randomized, controlled trial was to investigate the relationship between VAP and various methods of oral health care. All patients included in the study (n=142) were on mechanical ventilation with oral intubation at the intensive care unit of the Tokyo Dental College Ichikawa General Hospital. They were divided into two groups, one receiving standard oral health care (Standard group), and the other receiving oral health care using an oral moisture gel instead of water (Gel group). After removal of the intubation tube, biofilm on cuff of the tube was stained with a disclosing agent to determine the contamination level. Factors investigated included sex, age, number of remaining teeth, intubation time, fever ≥38.5°C, VAP, cuff contamination level, and time required for one oral health care session. No VAP occurred in either group during the study period. The level of cuff contamination was significantly lower in the Gel group than the Standard group, and the time required for one session of oral health care was shorter (p<0.001). Multivariate analysis revealed use of the oral moisture gel as a factor affecting cuff contamination level. Use of an oral moisture gel decreased invasion of the pharynx by bacteria and contaminants together with biofilm formation on the intubation tube cuff. These results suggest that oral health care using an oral moisture gel is effective in preventing cuff contamination.

Role of oral care to prevent VAP in mechanically ventilated Intensive Care Unit patients

Ventilator associated pneumonia (VAP) is the most common nosocomial infection in Intensive Care Unit. One major factor causing VAP is the aspiration of oral colonization because of poor oral care practices. We feel the role of simple measure like oral care is neglected, despite the ample evidence of it being instrumental in preventing VAP.

Measurement of salivary cortisol level for the diagnosis of critical illness-related corticosteroid insufficiency in children

OBJECTIVE

To compare serum total, serum free and salivary cortisol in critically ill children.

DESIGN

Prospective observational cohort study.

SETTING

Tertiary pediatric critical care unit at Ronald McDonald Children's Hospital at Loyola University Medical Center.

PATIENTS

We enrolled 59 patients (4 weeks to 18 years of age) between January 2012 and May 2013. Thirty-four patients were included in the salivary to serum free cortisol correlational analysis.

INTERVENTIONS

Blood and saliva samples were obtained simultaneously within 24 hours of admission between the hours of 6 AM and 12 PM. Salivary cortisol was tested by liquid chromatography/tandem mass spectrometry, serum free cortisol by liquid chromatography/tandem mass spectrometry followed by equilibrium dialysis, and serum total cortisol by liquid chromatography/tandem mass spectrometry.

MEASUREMENTS AND MAIN RESULTS

Salivary and serum free cortisol values from 34 patients had a correlation coefficient (r) of 0.87 (95% CI, 0.75-0.93; p < 0.0001). The total serum and salivary cortisol values had a correlation coefficient (r) of 0.67 (95% CI, 0.42-0.81; p < 0.0001). The total serum and serum free cortisol values had a correlation coefficient (r) of 0.83 (95% CI, 0.69-0.91; p < 0.0001).

CONCLUSIONS

Serum free and salivary cortisol values correlate in critically ill children. Salivary cortisol can be used as a surrogate for serum free cortisol in critically ill pediatric patients. Salivary cortisol is a cost-effective and less invasive measure of bioavailable cortisol and offers an alternate and accurate method for assessing critical illness-related corticosteroid insufficiency in children.

Oral care for intubated patients: a survey of intensive care unit nurses

AIMS

This study aimed to determine attitudes and practices of intensive care unit (ICU) nurses towards provision of oral care for intubated patients.

BACKGROUND

Oral care is as an essential nursing intervention for intubated patients to maintain patient comfort and prevent colonization of dental plaque by respiratory pathogens.

DESIGN

This was a cross-sectional study.

METHODS

Data were collected from 93 ICU nurses of a teaching hospital in the East Coast of Peninsular Malaysia using a self-administered questionnaire.

RESULTS

Some nurses agreed that oral cavity of intubated patients was difficult (40·8%) and unpleasant (16·2%) to clean, but all of them realized the importance of oral care and the majority (97·9%) would like to learn more about it. Most nurses reported providing oral care at least two times daily using various methods and products such as suction toothbrush (90·4%), manual toothbrush (49·5%), cotton swab (91·5%) and foam swab (65·7%). Chlorhexidine gluconate oral rinse was the preferred mouthwash (97·8%) and swabs (93·5%) solution although few used non-optimal products such as sodium bicarbonate (14·0%), tap water (4·3%) and hydrogen peroxide (3·2%) to wash their patients' mouths. While the majority of nurses agreed that oral care supplies and equipments were available (93·6%) and suitable (88·2%), most of them also thought they need better hospital support (88·2%).

CONCLUSIONS

The nurses' attitudes towards oral care were generally positive and most oral care methods were appropriate. However, some methods and products used were inconsistent with the current recommendations and they have mixed views about the suitability of oral care supplies and equipment provided by the hospital.

RELEVANCE TO CLINICAL PRACTICE

Recommendations were made for providing standard oral care protocols for intubated patients and oral care training programs for ICU nurses to support delivery of quality patient care.

Diurnal salivary cortisol measurement in the neurosurgical-surgical intensive care unit in critically ill acute trauma patients

Acute trauma patients represent a specific subgroup of the critically ill population due to sudden and dramatic changes in homeostasis and consequently extreme demands on the activity of the hypothalamic-pituitary-adrenocortical (HPA) axis. Salivary cortisol is an accepted surrogate for serum free cortisol in the assessment of HPA axis function. The purpose of this study was (1) to establish the feasibility of salivary cortisol measurement in acute trauma patients in the neurosurgical-surgical intensive care unit (NSICU), and (2) to determine the diurnal pattern of salivary cortisol in the acute phase after injury. Saliva from 50 acute trauma patients was prospectively collected twice a day at 6AM and 4PM during the first week after injury in the NSICU. Mean PM cortisol concentrations were significantly higher in subjects versus controls (p<0.001). Subjects failed to develop the expected PM versus AM decrease in cortisol concentration seen in controls (p=0.005). Salivary cortisol did not vary significantly with baseline Glasgow Coma Scale (GCS), Injury Severity Score, sex, injury type, ethnicity, or age. When comparing mean AM and PM salivary cortisol by GCS severity category (GCS ⩽8 and GCS >8) the AM salivary cortisol was significantly higher in patients with GCS ⩽8 (p=0.002). The results show a loss of diurnal cortisol variation in acute trauma patient in the NSICU during the first week of hospitalization. Patients with severe brain injury had higher morning cortisol levels than those with mild/moderate brain injury.

Gastrointestinal motility problems in critical care: a clinical perspective

Advances in surgery, anesthesia and intensive care have led to a dramatic increase in the number of patients who spend time in our intensive care units (ICU). Gastrointestinal (GI) motility disorders are common complications in the intensive care setting and are predictors of increased mortality and length of the stay in the ICU. Several risk factors for developing GI motility problems in the ICU setting have been identified and include sepsis, being on mechanical ventilation and the use of vasopressors, opioids or anticholinergic medications. Our focus is on the most common clinical manifestations of GI motor dysfunction in the ICU patient: gastroesophageal reflux, gastroparesis, ileus and acute pseudo-obstruction of the colon.

Oral health of patients under short hospitalization period: observational study

OBJECTIVE

To assess the impact of hospitalization on the oral health status of individuals hospitalized for a short period of time.

MATERIAL AND METHODS

This was an observational study of hospitalized patients. The plaque index (PI), gingival index (GI) was measured at baseline (T0 - first 24 h of hospital admission), and at 3 (T1), 7 (T2), 14 (T3) days.

RESULTS

One hundred and sixty-two patients were examined at baseline (T0), 35 examined at 3 days (T1), 23 at 7 days (T2) and 16 at 14 days (T3). The main reason for loss of patients was hospital discharge. The mean PI increased at T1 (0.97-1.21; p < 0.001), at T2 (1.06-1.30; p < 0.007) and at T3 (1.19-1.44; p < 0.03). Gingival index (GI) increased at T2 (0.74-0.96; p < 0.04) and at T3 (0.74-0.96; p < 0.02).

CONCLUSION

Oral health, assessed through PI and GI, deteriorates after a short period of hospitalization.

Implications of salivary protein binding to commensal and pathogenic bacteria

An important function of salivary proteins is to interact with microorganisms that enter the oral cavity. For some microbes, these interactions promote microbial colonization. For others, these interactions are deleterious and result in the elimination of the microbe from the mouth, This paper reviews recent studies of the interaction of salivary proteins with two model bacteria; the commensal species Streptococcus gordonii, and the facultative pathogen Staphylococcus aureus. These organisms selectively interact with a variety of salivary proteins to influence important functions such as bacterial adhesion to surfaces, evasion of host defense, bacterial nutrition and metabolism and gene expression.

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

AIM

To introduce the Bedside Oral Exam (BOE) and the Barrow Oral Care Protocol (BOCP) to guide oral care for intensive care unit patients. Secondary aim: To explore quality improvement data for incidence of ventilator associated pneumonia (VAP), cost effectiveness of oral hygiene supplies and staff response to change in practice.

METHODS

Descriptive case design for implementation and evaluation of oral assessments and oral hygiene. Incidence of VAP and the cost of oral care supplies before and after implementation was compared. Staff responses were elicited both pre- and post-implementation.

RESULTS

Incidence of VAP fell significantly from 4.21 to 2.1 per 1000 ventilator days (p =.04). A cost savings of 65% was noted on a monthly basis for oral hygiene supplies. Staff reported increased satisfaction in providing oral hygiene with a combination of oral care products.

CONCLUSIONS

A significant reduction in VAP was noted using the BOCP. The BOE guided individualised oral care with contemporary supplies, including a tongue scraper, electric toothbrush, non-foaming toothpaste and oral moisturisers. Cost-effective, comprehensive oral care appears to be effective in reducing VAP. Further studies are needed to assess impact of oral hygiene on oral health and patient comfort.

Host defense proteins derived from human saliva bind to Staphylococcus aureus

Proteins in human saliva are thought to modulate bacterial colonization of the oral cavity. Yet, information is sparse on how salivary proteins interact with systemic pathogens that transiently or permanently colonize the oral environment. Staphylococcus aureus is a pathogen that frequently colonizes the oral cavity and can cause respiratory disease in hospitalized patients at risk. Here, we investigated salivary protein binding to this organism upon exposure to saliva as a first step toward understanding the mechanism by which the organism can colonize the oral cavity of vulnerable patients. By using fluorescently labeled saliva and proteomic techniques, we demonstrated selective binding of major salivary components by S. aureus to include DMBT1(gp-340), mucin-7, secretory component, immunoglobulin A, immunoglobulin G, S100-A9, and lysozyme C. Biofilm-grown S. aureus strains bound fewer salivary components than in the planctonic state, particularly less salivary immunoglobulins. A corresponding adhesive component on the S. aureus surface responsible for binding salivary immunoglobulins was identified as staphylococcal protein A (SpA). However, SpA did not mediate binding of nonimmunoglobulin components, including mucin-7, indicating the involvement of additional bacterial surface adhesive components. These findings demonstrate that a limited number of salivary proteins, many of which are associated with various aspects of host defense, selectively bind to S. aureus and lead us to propose a possible role of saliva in colonization of the human mouth by this pathogen.

The impact of hospitalization on dental plaque accumulation: an observational study

AIM

To investigate the effect of hospitalization on oral health as assessed by dental plaque.

MATERIALS AND METHODS

Observational study in a critical care unit (CCU). Participants were recruited within 24 h of admission. Dental plaque amount was assessed at baseline, 1 and 2 weeks using the Debris index-soft deposits (Greene & Vermillion 1960).

RESULTS

Fifty participants were recruited with 36 available for outcome assessment at 1 week and 10 at 2 weeks. The principal reason for losses was early discharge with no evidence of a difference between patients present only at baseline and those present at 1 week. The median value for dental plaque at baseline was 4 (95% CI: 4, 6). The median dental plaque increase from baseline to week 1 was 1.5 (95% CI: -1, 4), and this was statistically significant (p = 0.04). The median increase from week 1 to week 2 was 1.0 (95% CI -8, 6) and not statistically significant (p = 0.68).

CONCLUSIONS

Oral health as assessed by dental plaque deteriorates following hospitalization in CCU. Such change could lead to impairment of quality of life and well-being as well as to increasing the risk of important healthcare-associated infections such as nosocomial pneumonia.