Effects of systematic oral care in critically ill patients: a multicenter study

Oral Health and Swallowing Function of Nursing Home Residents

OBJECTIVE

Although a good oral environment helps reduce the risk of pneumonia in the elderly, repeated pneumonia can occur even with frequent oral care. The actual risk of pneumonia during oral intake, the choice of whether oral intake is possible, and the choice of food form are often determined using video fluorography (VF), which can provide detailed information on swallowing function. However, few reports have compared the oral environment and swallowing function, leaving the relationship unclear. We examined the relationship between the oral environment and swallowing function and the characteristics of swallowing function in elderly nursing home residents.

METHODS

The subjects were 48 elderly nursing home residents (13 males, 35 females) with a mean age of 89 years who underwent outpatient or inpatient evaluation of their oral environment and swallowing function. There were three groups of residents: those who were evaluated for swallowing as outpatients, those who were hospitalised for pneumonia, and those who were hospitalised for diseases other than pneumonia. The oral environment was assessed by a dentist or dental hygienist using the Oral Health Assessment Tool (OHAT). Swallowing function was assessed by an otorhinolaryngologist using VF.

RESULTS

There was no correlation between OHAT and VF scores in the outpatient group or the group hospitalised for pneumonia, but there was a correlation in the group hospitalised for reasons other than pneumonia.

CONCLUSION

In facilities with good oral care, the development of pneumonia may be related to factors other than the oral environment and the OHAT may reflect conditions other than swallowing function. The swallowing function of nursing home residents should be evaluated by VF, which allows observation of all stages of swallowing.

The effect of artificial saliva on the control of dry mouth: a semi-experimental study on COVID-19 patients under Non-invasive mechanical ventilation

OBJECTIVES

Since maintaining oral hygiene is essential in nursing care, the present study was conducted to determine the effect of oral care using Mucosamin artificial saliva spray to control dry mouth in ICU patients with COVID-19.

MATERIALS AND METHODS

The current semi-experimental research was conducted on eighty patients with COVID-19 selected using the available sampling method. The study tool was a Beck oral assessment scale (BOAS). The case and control groups were selected from two hospitals with relatively similar conditions and treatment procedures. For patients in the intervention group, mucosamin artificial saliva spray was used in addition to the common care, while control group patients received only common care.

RESULTS

Eighty patients were randomly assigned to two groups named control and intervention (40 patients in each group). The intervention was very effective in reducing the BOAS score after four days in comparison with the control group (9.23 vs. 12.05, respectively; p-value < 0.001). Based on the adjusted model, the application of artificial saliva reduced the BOAS score, indicating improvement in mouth dryness. While the BOAS score was increased in the control group, it had a declining trend in the intervention one.

CONCLUSION

The study's results showed that using artificial saliva spray could effectively reduce the symptoms of dry mouth in patients with COVID-19 treated with non-invasive mechanical ventilation.

CLINICAL RELEVANCE

The present study introduced an applicable solution (artificial saliva) to treat mouth dryness in ICU patients under mechanical ventilation.

Effect of propolis mouthwash on the incidence of ventilator-associated pneumonia in intensive care unit patients: a comparative randomized triple-blind clinical trial

OBJECTIVES

Ventilator-associated pneumonia (VAP) increases the length of hospitalization and mortality rate. This study aimed to determine the effect of propolis mouthwash on the incidence of VAP in intensive care unit (ICU) patients.

MATERIALS AND METHODS

Triple-blind, comparative randomized, controlled clinical trial was conducted over one year, with 110 ICU patients at Imam-Hossein and Bahar hospitals (Shahroud) and Kowsar Hospital (Semnan) in Iran. The intervention group used 15 cc of 0.06% propolis mouthwash solution twice daily at 8 AM and 4 PM for seven days. The control group used 15 cc of 0.2% chlorhexidine mouthwash at the same times and duration. Data were collected using a demographic questionnaire, APACHE II, Beck Oral Assessment Scale, and Modified Clinical Pulmonary Infection Score (MCPIS).

RESULTS

There was no significant difference in demographic information, disease severity, and oral health between the two groups before and after intervention (P > 0.05). The incidence of VAP in the intervention group compared to the control group was 10.9% vs. 30.9% on the third day (P = 0.0166, 95% CI: 0.53-0.83 and RR = 0.35), 23.6% vs. 43.6% on the fifth day (P = 0.0325 and 95% CI: 0.31-0.95 and RR = 0.54), and 25.5% vs. 47.3% on the seventh day (P = 0.0224, 95% CI: 0.32-0.92, and RR = 0.54). The Mann-Whitney indicated the incidence of VAP was significantly lower in the intervention group on the third, fifth, and seventh days.

CONCLUSION

Propolis mouthwash can be considered as an alternative to chlorhexidine mouthwash for ICU patients.

CLINICAL RELEVANCE

Propolis mouthwash serves as a simple, economical intervention to potentially reduce incidence of VAP.

TRIAL REGISTRATION

(IRCT20110427006318N12, date 02.04.2019).

Impact of various solutions on the oral health status of critically ill patients

Oral care is a crucial challenge of nursing care in orally intubated patients. Oropharyngeal colonization with microorganisms is probably the first step in the pathogenesis of most bacterial pulmonary infections. This study aimed to investigate the effect of different oral care solutions on the oral health status of critically ill patients. We conducted a quasi-experimental study involving a convenience sample of 60 adult orally intubated patients, distributed equally into three groups: 20 patients received 0.12% chlorhexidine gluconate (CHX) solution as an oral rinse; 20 patients received 0.1% hexetidine (HEX) solution as an oral rinse; and a control group of 20 patients received routine hospital oral care with 0.9% normal saline (NS) solution. Oropharyngeal and tracheal cultures were obtained from patients within 24-48 h of admission, before the administration of topical oral antimicrobial solutions and then repeated on day 4 and day 7 after the oral solutions. The study revealed that CHX has a more powerful effect than HEX and NS in improving the oral mucosa and decreasing colonization of both the oropharynx and trachea. On day 7, the improvements were statistically significant in the CHX group and the HEX group (P = 0.02 and P = 0.03, respectively), but not in the NS group. This research confirms the effect of CHX and HEX in lowering the risk of tracheal and oropharyngeal colonization, and recommends the use of a CHX solution as oral mouth care in critically ill patients.

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.

Quantitative oral health assessments in mechanically ventilated patients: A scoping review

BACKGROUND

Oral health is a key contributor to a person's overall health. Previous studies indicate that oral health deteriorates throughout ventilation and may contribute to the development of ventilator-associated pneumonia (VAP). Oral health at the time of initial ventilation may impact on this deterioration.

AIMS

To determine the quantitative clinical assessment methods used to measure oral health and what is currently known regarding the oral health of patients at the time of initial ventilation.

STUDY DESIGN

A systematic literature search using electronic bibliographic databases MEDLINE/PubMed, Embase, CINAHL, and the Cochrane Library was undertaken for this scoping review. Studies were included if patients were >18 years old and mechanically ventilated for <48 h at the time of the first oral assessment.

RESULTS

In total, 12 studies were included. The review demonstrates a limited understanding of clinical oral health at the time of initial ventilation. Significant variation in both assessment methods and reporting of oral health makes comparison of results difficult resulting in a poor overall understanding of oral health at the time of intubation.

CONCLUSION

Standardized assessment and reporting methods may improve clinical application of findings and help direct future research. We suggest developing a core outcome set to ensure consistent use of assessment tools as well as standardized reporting of results.

RELEVANCE TO CLINICAL PRACTICE

It is essential that a good understanding of oral health at the time of initial ventilation is gained so that patients receive more targeted oral hygiene intervention in ICU, potentially leading to improved patient outcomes.

Poor Oral Health in Trauma Intensive Care Unit Patients: Application of a Novel Oral Health Score

Background: Although oral hygiene in patients in the intensive care unit (ICU) has been shown to reduce hospital-associated infections, baseline and progressive oral health are often not reported because of lack of a standardized tool. The Oral Health Risk Assessment Value Index (OHRAVI) is a comprehensive oral assessment validated by dental providers. This study hypothesizes that non-dental providers can use OHRAVI in trauma ICU patients with minimal training and acceptable inter-rater reliability (IRR). Patients and Methods: Dentulous adult patients in the ICU at a level 1 trauma center were scored, excluding those with severe orofacial trauma. The eight categories of the OHRAVI were scored 0 to 3 (best to worst) with summed total and index (average) score. Index scores 1 or less need routine oral care; greater than 1-2 require moderate care; and greater than 2-3 require extensive oromaxillofacial care. Inter-rater reliability was assessed by two to three raters with Krippendorff's α (≥0.80 for good and ≥0.667 for acceptable). Results: Eighty-four ratings were completed across 34 patients, with 16 patients (47%) scored by all three raters. Ten patients (29%) had an index score <1. The average index score for patients was 1.28 (median, 1.34; range, 0.63-2). Krippendorff's α for index score was 0.86. For individual categories, α ranged from 0.44 to 1, with six of the eight categories achieving an α ≥ 0.667. Conclusions: With minimal training, non-dental providers were able to use OHRAVI with a good IRR for index score and an acceptable/good IRR for most individual categories. This novel, simple, comprehensive oral health score could help standardize oral assessment and facilitate future studies of peri-operative oral hygiene interventions.

Effect of clove mouthwash on the incidence of ventilator-associated pneumonia in intensive care unit patients: a comparative randomized triple-blind clinical trial

OBJECTIVES

Ventilator-associated pneumonia (VAP) is one of the most common nosocomial infections in intensive care units (ICUs), and the use of mouthwash is the most widely used method to prevent its incidence. The aim of this study was to investigate effect of clove mouthwash on the incidence of VAP in the ICU.

MATERIALS AND METHODS

This comparative, randomized, triple-blind, clinical trial was conducted on 168 eligible ICU patients at Kosar Hospital in Semnan, Iran, during 2021-2022, who were divided into intervention and control groups using random blocks. The intervention group received clove extract mouthwash at 6.66% concentration, and the control group received chlorhexidine 0.2% twice a day for 5 days (routine care). Data were collected using a demographic questionnaire, and disease severity was measured based on the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, oral health status was examined using the Beck Oral Assessment Scale (BOAS), and VAP diagnosis was made based on the Modified Clinical Pulmonary Infection Score (MCPIS).

RESULTS

Before the intervention, there was no significant difference in disease severity (p = 0.412) and oral health status (p = 0.239) between the patients in the two groups. After the intervention, 20.2% of the patients in the intervention group and 41.7% of those in the control group acquired VAP. The risk of VAP was 2.06 times higher in the control group than in the intervention group (p = 0.005, 95% CI: 1.26-3.37, RR = 2.06), but the severity of VAP did not differ significantly between the patients in the two groups (p = 0.557).

CONCLUSION

The findings showed that clove mouthwash reduces the incidence of VAP significantly.

CLINICAL RELEVANCE

Clove mouthwash can be used as a simple and low-cost method to prevent VAP in ICU patients.

Impact of tooth brushing on oral bacteriota and health care-associated infections among ventilated COVID-19 patients: an intervention study

BACKGROUND

Up to 48% of ventilated coronavirus disease 2019 (COVID-19) patients develop ventilator-associated pneumonia (VAP) during hospitalization in an ICU. Dysbiotic oral microbiota can colonize the lower respiratory tract and lead to VAP. It is recommended to introduce oral care strategies in the ICU to prevent VAP. In this study, we observed the impact of an oral hygienic protocol with tooth brushing on cultivable oral bacteriota, the incidence of HAI and patient safety among mechanically ventilated COVID-19 patients in an ICU setting.

METHODS

In this prospective cohort study, we recruited 56 adult COVID-19 patients who qualified for mechanical ventilation. Patients were divided into 2 groups depending on the oral care procedure: standard and extended oral procedures with tooth brushing. Oral bacteriota samples were taken first within 36 h and after 7 days of intubation. Microorganisms were identified by MALDI/TOF mass spectrometry. bacterial health care-associated infection (HAI) cases were retrospectively analyzed by etiology. A PFGE study was performed for Klebsiella pneumoniae to check for clonal spreading of strains from oral bacteriota samples and HAI cases.

RESULTS

We observed significant dysbiosis and a decrease in cultivable oral bacteriota diversity, with a high frequency of potentially pathogenic species, including Acinetobacter baumannii and K. pneumoniae. The HAI incidence rate was high (55.2/1000 patient-days), most commonly of K. pneumoniae and A. baumannii etiologies, which correlated with the presence of A. baumannii and K. pneumoniae in the oral samples. Strains isolated from VAP cases were the same as oral isolates in 8 cases. The procedure with tooth brushing led to less frequent identification of A. baumannii in oral samples (55.6% vs. 5.3%, p = 0.001); however, it did not decrease the incidence of HAIs.

CONCLUSIONS

Dysbiotic oral bacteriota is an important source of respiratory pathogens. The introduction of tooth brushing in oral hygiene protocols in an ICU setting was effective in decreasing the extent of oral bacteriota dysbiosis; however, it did not reduce the risk of HAIs or mortality.

TRIAL REGISTRATION

1072.6120.333.2020.

Association Between Oral Health and Swallowing Function in the Elderly

Objective

Although the oral environment significantly affects the risk of pneumonia, there have been few studies regarding its relation with swallowing. There is no doubt that there is a significant link between the oral environment and the development of pneumonia; however, there have been few comparative studies of swallowing using video endoscopy (VE) and video fluorography (VF) as indicators to determine the actual availability of oral intake and the choice of food form. This study was performed to examine whether the oral environment or swallowing function contributes more to the development of pneumonia in the elderly.

Methods

The study population consisted of 24 patients (7 men and 17 women; age range: 64-97 years; average age: 86 years) assessed using the Oral Health Assessment Tool (OHAT), VE and VF at Fukuoka Dental College Hospital. The most common disease was pneumonia (17 patients), followed by cerebral infarction (5 patients), pyelonephritis (4 patients), bronchitis (2 patients), Parkinson's disease (2 patients), scleroderma (1 patient), diabetes (1 patient), eosophageal cancer (1 patient) and Parkinson's syndrome> (1 patient). Some patients had multiple diseases. Oral intake was possible in 20 patients (80%), whereas tube feeding and gastric banding were required in 4 patients.

Results

The OHAT score was not correlated with either the VE or VF score. Furthermore, the OHAT score was not significantly different between the multiple- and no/single-pneumonia episode groups. The group with multiple episodes of pneumonia had lower VE and VF scores than those with no or only a single episode of pneumonia.

Conclusion

Oral assessment, VE and VF are necessary to evaluate swallowing in patients with suspected dysphagia. Swallowing function, especially as assessed by VE and VF, is more important than examination of the oral environment for evaluating risk of recurrent aspiration pneumonia in the elderly. In addition, multiple factors contribute to recurrent pneumonia in patients with a good oral environment, including subclinical aspiration, pharyngeal clearance and delayed activation of the gag reflex.

Cultivable oral bacteriota dysbiosis in mechanically ventilated COVID-19 patients

Potential interactions between the SARS-CoV-2 virus and the human oral microbiota are currently investigated widely. Patients with COVID-19 requiring mechanical ventilation in an intensive care unit (ICU) setting are at high risk of developing severe complications, including ventilator-associated pneumonia, thus making oral health management important. The aim of this study was to evaluate the oral health status and assess the dysbiosis of cultivable oral bacteriota in COVID-19 patients hospitalized in an ICU with acute respiratory distress within 36 h following intubation. In this prospective cohort study, we recruited 56 adult COVID-19 patients that qualified for mechanical ventilation in the Temporary ICU for COVID-19 Patients of the University Hospital in Krakow. On admission to the ICU, oral health of patients was assessed using the modified Beck Oral Assessment Score (BOAS). Four oral habitats were sampled, namely the buccal mucosa, tongue, buccal dental surface and gingival pocket. Microorganisms were identified by MALDI/TOF mass spectrometry. The mean age of the study population was 66.5 ± 12.7 years, there were 24 (42.9%) females. All patients included in this study were intubated and ventilated in the ICU, with a corresponding high mortality rate (76.8%). On admission to ICU, 76.8% subjects scored 11–20 on the BOAS scale (median 12 [IQR 10–14]), indicating moderate or severe dysfunction of oral health. Potentially pathogenic bacteria were identified in the oral microbiota samples, including Acinetobacter baumannii, Enterococcus faecalis, Escherichia coli and Klebsiella pneumoniae in 23.2%, 39.3%, 17.9%, and 19.6% of patients, respectively. Lactobacillus spp. were present in 57.1% subjects. The mean CFU counts of all bacteria strains in dental brushes were 9.3E+5 (1.4E+6) and in gingival pockets 7.6E+5 (1.4E+6). The highest CFU counts were observed for Enterococcus spp. and, Lactobacillus spp., although these did not differ significantly from CFU counts of Streptococcus spp. and Staphylococcus spp. In this report we comprehensively characterized the oral health condition and cultivable oral bacteriota in COVID-19 patients hospitalized in an ICU with acute respiratory distress within 36 h following intubation. The oral bacteriota showed significant qualitative and quantitative dysbiosis. Hospitalization in an ICU and mechanical ventilation are important factors leading to oral dysbiosis in SARS-CoV-2 patients.

Efficacy of Moraceae with chlorhexidine mouthwash on the microbial flora of critically ill intubated patients: a randomized controlled pilot study

Critically ill intubated patients are routinely provided with chlorhexidine (CHX) for their mouth washing, but CHX mouthwash induces several complications. In this study, we aimed to evaluate the efficacy and safety of Moraceae with CHX mouthwash in the reduction of oral bacterial count in critically ill patients and to compare it with CHX-alone mouthwash. This double-blind, randomized, controlled trial included critically ill patients receiving mechanical ventilation. The patients were randomly divided into two groups based on the Modified Beck oral assessment score. The primary endpoint was a reduction in oral bacterial counts after mouth washing on day 1 and day 4. Thirty patients were included in this study; 15 patients received Moraceae with CHX mouthwash and 15 patients received CHX-alone mouthwash. The oral bacterial counts in the Moraceae with CHX group did not differ from the CHX group after mouth washing on day 1 and day 4 of admission. The patients in the CHX group experienced more intolerable taste than those in the Moraceae group (60% vs. 13.3%, P = 0.008). Moraceae with CHX mouthwash had the same effectiveness as CHX alone on bacterial flora but exhibited less intolerable side effects than CHX alone.Trial registration: TCTR20190530003; 30/05/2019.

Oral Care Practice, Perception, and Attitude of Nurses in Intensive Care Units in Korea: A Questionnaire Survey

Background: This cross-sectional study investigated the factors influencing oral care in patients in intensive care units (ICUs) by identifying the current oral care practice status, perceptions, and attitudes of ICU nurses in Korea. Methods: This study surveyed 240 nurses with work experience in the ICU using a self-report questionnaire consisting of 22 items on the status, perception, and attitude towards oral care in the ICU. Results: A total of 227 questionnaires were analyzed. The average age of the participants was 29.79 ± 5.92 years, and the medical ICU was the most type of ICU. The factors affecting the attitude towards oral care and its importance in ICU patients were the experience of working as a nurse (r = 0.336, p < 0.01), ICU work experience (r = 0.218, p < 0.01), and oral care practice frequency (r = 0.167 p < 0.05); these were found to be statistically significant. Conclusions: In this study, the interest of the nurses in oral care practice and education was high, but professional education and the regular implementation of oral care practices were insufficient. To address these problems, it will be necessary to improve oral care practices through dental intervention and education about oral care methods focused on ICU patients.

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.

Oral Management by a Full-Time Resident Dentist in the Hospital Ward Reduces the Incidence of Pneumonia in Patients with Acute Stroke

Background. A full-time dentist was assigned to a ward at our hospital to improve the quality of oral healthcare for hospitalized patients. A dental care system (DCS) was created to facilitate the collaboration between the full-time dentist and the nursing department. Objective. To investigate the effects of DCS implementation on the incidence of pneumonia in patients with acute stroke. Methods. This retrospective cohort study comprised 945 hospitalized acute stroke patients categorized into three groups: pre-, during-, and post-DCS. The DCS comprised dentist-led lectures and practical sessions, oral assessments, standardized oral care techniques, and information on the procedures for nurse-requested dental intervention. Data were extracted from the Japanese Diagnosis Procedure Combination database and medical records. The attributes of the patients, incidence of pneumonia, and number of patients who requested dental intervention were determined. Results. The odds ratios of pneumonia onset were 3.16 (95% confidence interval [CI], 1.65–6.05; $P=0.001$ ) in the pre-DCS and 2.80 (95% CI, 1.48–5.31; $P=0.002$ ) in the during-DCS group compared with the post-DCS group, thereby confirming the effect of DCS on the incidence of pneumonia. The number of dental requests in the post-DCS group was noted to be higher than that in the pre-DCS group ( $P=0.002$ ). Conclusion. Oral management by a full-time dentist was found to be effective in reducing the incidence of pneumonia in patients with acute stroke. To implement the best oral care practices in the hospital wards, the full-time dentist should work as a member of the medical team.

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.

Lost Dental Bridges During ICU Stay

Oral care is easily neglected in patients in an intensive care unit (ICU) because they are often intubated or have altered mental status. Although care workers pay careful attention to the mouth, tooth loss often occurs in the ICU. Here we report 3 cases of dental bridge loss undetected by the ICU staff. One patient was under mechanical ventilation via an endotracheal tube after emergency intubation, whilst 2 patients were drowsy but not intubated. Consecutive chest X-rays revealed dental bridge loss in all 3 cases, but this was not identified immediately. Along with other critical management approaches, these cases demonstrate how an initial evaluation of the oral cavity, with special attention to the number of teeth, and the existence of dental prosthetics is essential to preventing potential deleterious complications. The number of teeth and the existence of dental prosthetics must be documented in ICU patients.

Comparative Study of the Effect of Three Oral Care Protocols on Ventilator-Associated Pneumonia in Critically Ill Patients: A Clinical Trial

BACKGROUND

Oral care plays a significant role in reducing the incidence of Ventilator-Associated Pneumonia (VAP) in Intensive Care Units (ICUs). The aim of this study was to investigate the effect of three oral care protocols on the incidence of VAP in Mechanically-Ventilated (MV) patients hospitalized in ICUs.

MATERIALS AND METHODS

This parallel randomized clinical trial was performed in 2019 on 71 MV adult patients with endotracheal intubation hospitalized in ICUs. The patients were divided into three groups: a 7-day oral care by using swab (group 1), two-times-brushing group (group 2), and four-times-brushing group (group 3) by using chlorhexidine. The data related to the incidence of pneumonia were analyzed during several days using Chi-square and ANOVA tests.

RESULTS

The incidence of pneumonia on the fourth day of the intervention in the first group (35.00%) was significantly higher than that of the two intervention groups (10.00%) (χ ² = 5.86, df = 2, p = 0.03)). The mean score of modified clinical pulmonary infection in the third group was significantly lower seven days after the intervention than before the intervention (p = 0.04) and the fourth day of intervention (p = 0.003). In the first group, this score was significantly higher in the fourth day of the intervention than the seventh day (p = 0.003).

CONCLUSIONS

Based on the results, the oral care protocol, including four-times-brushing, reduced the risk of VAP more than two times brushing. Therefore, the use of this protocol is recommended to provide a minimum level of oral care and reduce the risk of VAP in MV patients.

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 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.

Oral mucosal mouthwash with chlorhexidine does not reduce the incidence of ventilator-associated pneumonia in critically ill children: A randomised controlled trial

BACKGROUND

Ventilator-associated pneumonia (VAP) is one of the most frequently encountered causes of hospital-acquired infection and results in high morbidity among intubated patients. Few trials have investigated the efficacy of oral care with chlorhexidine (CHX) mouthwash for the prevention of VAP in the paediatric population.

OBJECTIVES

The objective of this study was to assess the efficacy of CHX mouthwash in the prevention of VAP and to determine risk factors for VAP in children aged 1 month to 18 years admitted to the paediatric intensive care unit (PICU).

METHODS

This was a prospective, randomised, controlled, double-blind trial performed in the PICU. Patients were randomised into two groups receiving CHX (0.12%) (n = 88) or placebo (0.9% NaCl) (n = 86) and were followed up for VAP development. The main outcome measures were incidence of VAP, duration of hospital stay, duration of PICU stay, duration of ventilation, mortality, and the characteristics of organisms isolated in cases with VAP.

RESULTS

No difference was observed in the incidence of VAP and the type and distribution of organisms in the two groups (p > 0.05). In the CHX and placebo groups, we identified 21 and 22 patients with VAP, respectively. Incidence per 1000 ventilation days was 29.5 events in the CHX group and 35.1 events in the placebo group. Gram-negative bacteria were most common (71.4% in CHX vs. 54.5% in placebo). The use of 0.12% CHX did not influence hospital stay, PICU stay, ventilation, and mortality (p > 0.05). Multivariate analysis identified duration of ventilation as the only independent risk factor for VAP (p = 0.001).

CONCLUSION

The use of 0.12% CHX did not reduce VAP frequency among critically ill children. The only factor that increased VAP frequency was longer duration on ventilation. It appears that low concentration of CHX is not effective for VAP prevention, especially in the presence of multiresistant bacteria. CLINICALTRIALS.

GOV IDENTIFIER

NCT04527276.

Evidence-based bundled care for patients with dysphagia after severe traumatic brain injury: a randomized controlled trial

OBJECTIVE

To explore the effect of an evidence-based bundled care model in patients with dysphagia after severe traumatic brain injury (TBI).

METHODS

This is a prospective randomized controlled study. A total of 60 patients with dysphagia after severe TBI (traumatic brain injury) admitted to the Department of Rehabilitation Medicine were selected and randomly divided into the test group (n=30) and the control group (n=30). Patients in the control group received routine care in the Department of Rehabilitation Medicine, while patients in the test group received evidence-based bundled care on the basis of the treatment of the control group. The improvement of swallowing function (dye test in comatose patients), oral hygiene, and nutritional risk was assessed in both groups. The incidence of adverse events such as aspiration and aspiration pneumonia, as well as the length and costs of hospitalization were compared between the two groups.

RESULTS

Compared with patients in the control group, swallowing function of patients in the test group was significantly improved after the care (P<0.05), and for comatose patients, the positive rate of Evans blue dye test was markedly reduced (P<0.05). Compared with patients in the control group, the oral hygiene of patients in the test group was significantly improved after care, and the nutritional risk scores were also significantly decreased (P<0.05). During hospitalization, the total incidence of adverse events, length and costs of hospitalization of patients in the test group were significantly lower than those in the control group (P<0.05).

CONCLUSION

Evidence-based bundled care can effectively improve swallowing function and reduce the incidence of nutritional risks and adverse events in patients with dysphagia after severe TBI, which further promotes postoperative rehabilitation of patients.

Effect of 0.12% Chlorhexidine Use for Oral Care on Ventilator-Associated Respiratory Infections: A Randomized Controlled Trial

BACKGROUND

Evidence suggests that the effect of 0.12% chlorhexidine (CHX) use for oral care on the development of ventilator-associated pneumonia (VAP) and ventilator-associated tracheobronchitis (VAT) is lacking. Evidence-based approaches to the prevention of VAP and VAT are of paramount importance for improving patients' outcomes.

OBJECTIVES

This study aimed to (1) compare the effect of 0.12% CHX use for oral care on preventing VAP and VAT with the placebo group, as well as (2) compare its effect on oral health and prevention of oral microbial colonization with the placebo group.

METHODS

Prospective, single-blinded, randomized controlled trial performed in 2 intensive care units at a hospital. The sample comprised 57 mechanically ventilated adults randomly allocated to the 0.12% CHX group and the placebo group. Barnason's oral assessment guide was used to evaluate the oral health of both groups before oral care during the first 24 hr of tracheal intubation (Day 0) and at Day 2 and Day 3. Oropharyngeal secretion, endotracheal tube aspirate, and nonbronchoscopic bronchoalveolar lavage samples were collected on Day 0 and Day 3.

RESULTS

The rate of VAT development was not statistically different between the groups (p = .318). However, a significant difference existed in the rate of VAP development (p = .043). The frequency of oropharyngeal colonization significantly decreased in the 0.12% CHX group compared with the placebo group at Day 3 (p = .001).

CONCLUSION

The use of 0.12% CHX for oral care could be effective for VAP prevention and reducing microbial colonization in mechanically ventilated patients.

Effects of different oral care strategies on postoperative pneumonia in infants with mechanical ventilation after cardiac surgery: a prospective randomized controlled study

BACKGROUND

To explore the effects of different oral care strategies on postoperative pneumonia in infants with mechanical ventilation after cardiac surgery.

METHODS

A prospective randomized controlled study was conducted at a hospital in Fujian Province, China. Participants were randomly divided into the breast milk oral care group, physiological saline oral care group, and sodium bicarbonate oral care group to explore the effects of different oral care strategies on postoperative pneumonia in infants on mechanical ventilation cardiac surgery.

RESULTS

The mechanical ventilation duration, the hospitalization costs, and the length of intensive care unit (ICU) stay and postoperative hospital stay in the breast milk oral care group were significantly shorter than those in the physiological saline oral care group and the sodium bicarbonate oral care group. The incidence of postoperative pneumonia in the breast milk oral care group was 3.2%, which was significantly lower than that in the physiological saline oral care group (22.6%) and the sodium bicarbonate oral care group (19.4%).

CONCLUSIONS

Using breast milk for oral care in infants after cardiac surgery has a lower incidence of postoperative pneumonia than traditional oral care strategies of physiological saline and sodium bicarbonate, and it is worthy of clinical application.

Relationship between oral intake level and oral health assessment tool scores in the convalescent ward

PURPOSE

To examine the relationship between oral intake function and oral health status in convalescent inpatients.

METHODS

Subjects were 222 patients admitted to a convalescent hospital between 1 January and 30 June 2018. Investigation items were age, sex, causative disease, body mass index, functional oral intake scale (FOIS), functional independence measure, occlusal contact, assistance with oral cleaning, and oral health assessment tool (OHAT) scores. Multiple regression analysis was performed with FOIS as the dependent variable, and investigation items were related to FOIS as independent variables.

RESULTS

Results of multiple regression analysis for all patients suggested that saliva and denture scores were significantly associated with FOIS. However, analysis excluding non-oral feeding patients did not show a significant association between FOIS and OHAT scores.

CONCLUSION

The results of this study suggest that oral health status is associated with oral intake function. In addition, the oral health status of inpatients may be strongly related to whether or not they are eating orally. Therefore, it is necessary to take good care of oral health in non-oral feeding patients in the convalescent ward.

Impact of oral hygiene in patients undergoing mechanical ventilation in the COVID-19 pandemic

COVID-19, caused by SARS-CoV-2, can present respiratory complications that often lead patients to depend on mechanical ventilation (MV) for several days. It is known that Pneumonia Associated with Mechanical Ventilation (PAMV) is frequent in patients who use this equipment for a long time. As a consequence of COVID-19, its prolonged use can lead to a worse prognosis for the patients. For this reason, in addition to the insufficiency of devices for mechanical ventilation to meet the current demand, it is necessary to adopt measures aimed at preventing complications that may aggravate the patient's clinical condition and, consequently, increase the average hospital stay and the respective hospital care costs. Therefore, the objective of this study was to discuss, in a concise and practical way, and based on the available literature, the importance of adopting adequate oral hygiene protocols for patients on mechanical ventilation. Based on the data obtained, it was identified that the adoption of effective oral hygiene measures, especially under the supervision of dental professionals, can contribute to the reduction of morbidity and mortality associated with MV, resulting in greater availability of mechanical ventilation equipment. Since such equipment is in great demand during the COVID-19 pandemic, the knowledge and implementation of effective oral hygiene measures will undoubtedly have an impact on improving the quality of care offered to patients, therefore benefiting all those in critical health conditions and assisted in ICUs.

Oral care - identifying quality improvement areas

PURPOSE

The purpose of this paper is to describe and compare nurses' and healthcare assistants' oral care quality perceptions, including perceived reality (PR) and subjective importance (SI), to identify improvement areas in intensive care and short-term care, and to explore potential nursing satisfaction predictors regarding oral care.

DESIGN/METHODOLOGY/APPROACH

Swedish staff, 154 within intensive care and 278 within short-term care responded to a modified quality of care from a patient perspective questionnaire. Descriptive and analytical statistics were used.

FINDINGS

Staff scored oral care quality both high and low in relation to PR and SI. Improvement areas were identified, despite high satisfaction values regarding oral care. Setting, SI and PR explained 51.5 percent of the variance in staff satisfaction regarding oral care quality.

PRACTICAL IMPLICATIONS

Quality improvements could guide oral care development.

ORIGINALITY/VALUE

This study describes oral care by comparing nurse perceptions of how important they perceive different oral care aspects and to what extent these oral care aspects are performed.

Implementation strategies used to implement nursing guidelines in daily practice: A systematic review

OBJECTIVES

Research specifically addressing implementation strategies regarding nursing guidelines is limited. The objective of this review was to provide an overview of strategies used to implement nursing guidelines in all nursing fields, as well as the effects of these strategies on patient-related nursing outcomes and guideline adherence. Ideally, the findings would help guideline developers, healthcare professionals and organizations to implement nursing guidelines in practice.

DESIGN

Systematic review. PROSPERO registration number: CRD42018104615.

DATA SOURCES

We searched the Embase, Medline, PsycINFO, Web of Science, Cochrane, CINAHL and Google Scholar databases until August 2019 as well as the reference lists of relevant articles.

REVIEW METHODS

Studies were included that described quantitative data on the effect of implementation strategies and implementation outcomes of any type of a nursing guideline in any setting. No language or date of publication restriction was used. The Cochrane Effective Practice and Organisation of Care taxonomy was used to categorize the implementation strategies. Studies were classified as effective if a significant change in either patient-related nursing outcomes or guideline adherence was described. Strength of the evidence was evaluated using the 'Cochrane risk of bias tool' for controlled studies, and the 'Newcastle-Ottawa Quality Assessment form' for cohort studies.

RESULTS

A total of 54 articles regarding 53 different guideline implementation studies were included. Fifteen were (cluster) Randomized Controlled Trials or controlled before-after studies and 38 studies had a before-after design. The topics of the implemented guidelines were diverse, mostly concerning skin care (n = 9) and infection prevention (n = 7). Studies were predominantly performed in hospitals (n = 34) and nursing homes (n = 11). Thirty studies showed a positive significant effect in either patient-related nursing outcomes or guideline adherence (68%, n = 36). The median number of implementation strategies used was 6 (IQR 4-8) per study. Educational strategies were used in nearly all studies (98.1%, n = 52), followed by deployment of local opinion leaders (54.7%, n = 29) and audit and feedback (41.5%, n = 22). Twenty-three (43.4%) studies performed a barrier assessment, nineteen used tailored strategies.

CONCLUSIONS

A wide variety of implementation strategies are used to implement nursing guidelines. Not one single strategy, or combination of strategies, can be linked directly to successful implementation of nursing guidelines. Overall, thirty-six studies (68%) reported a positive significant effect of the implementation of guidelines on patient-related nursing outcomes or guideline adherence. Future studies should use a standardized reporting checklist to ensure a detailed description of the used implementation strategies to increase reproducibility and understanding of outcomes.

Nurses' attitude towards oral care and their practicing level for hospitalized patients in Orotta National Referral Hospital, Asmara-Eritrea: a cross-sectional study

BACKGROUND

Effective and routine mouth care is necessary for hospitalized patients as it helps to maintain the health of oral cavity and overall health. However, oral care is often overlooked and not prioritized in daily activity plan of nurses even when oral problems are apparent. Therefore, the aim of this study was to assess nurses' attitude towards oral care and their practicing level for hospitalized patients.

METHODS

A cross-sectional study design was conducted in adult medical-surgical department of Orotta hospital from December 2017 to January 2018. Data was collected from all (N = 73) diploma and associate nurses through face to face interview using a pretested and structured questionnaire. Kruskal-Wallis, Mann-Whitney U tests and spearman rank correlation coefficient tools were performed to analyze the data using SPSS (Version 22).

RESULTS

Out of the 79 participants, 73 completed the interview successfully with a response rate of 92.4%. Of the total, 56.2% were diploma nurses and 43.9% were associate nurses. The median attitude score was 68.89/100 (IQR = 48.89). The majority (94.5%) of the nurses agreed that oral cavity assessment is nurse's responsibility and 94.5% reported adequate training is needed to provide quality oral care. On the other hand, the median practice score was 50.00/100 (IQR = 17.86). Majority of the participants (76.7%) did not perform routine oral health assessment. Almost all (98.4%) used gauze and normal saline for oral care. Practice score was significantly different across the various wards (p < 0.001), however, it was not significantly correlated with attitude (p = 0.646).

CONCLUSIONS

The participants had poor level of oral care practice to hospitalized patients, nevertheless, they had favourable attitude. Therefore, Orotta National Referral Hospital needs to give further effort to train the nursing staff, ensure the availability of adequate oral care equipment and provide clear guidelines regarding oral care of hospitalized patients.

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.

Do nurses have barriers to quality oral care practice at a generalized hospital care in Asmara, Eritrea? A cross-sectional study

BACKGROUND

Oral care is a fundamental nursing practice that has a great impact on patient well-being and general health during hospitalization. Nurses are responsible for providing oral care in the hospital, however, they usually implement it unsatisfactorily due to inadequate resources, lack of standard protocol, time shortage and ineffective training. The aim of the study was, therefore, to assess nurses' barriers to quality oral care practice at a generalized hospital. The information obtained will help in highlighting the magnitude of the problem and in the promotion of oral health, prevention and control of oral diseases, reduction of hospital stays and diseases, and in strengthening healthcare systems.

METHODS

A cross-sectional design using mixed (quant-qual) method was applied at a generalized hospital. Data for the quantitative study were collected from all (N = 73) diploma and associate nurses through face to face interview with a structured questionnaire. On the other hand, in the qualitative part, head nurses (n = 6) and staff nurses (n = 7) discretely participated in the focus group discussions (FGDs), whereas matron (n = 1), assistant matrons (n = 2), and supervisor (n = 1) in total 4, participated in the key informant interview (KII). The quantitative and qualitative data were analyzed, respectively, using descriptive statistics and thematic framework analysis.

RESULTS

The majority (93.2%) of participants had barriers performing oral care. The barriers mentioned by the participants were; lack of oral care equipment (91.2%), absence of guidelines (73.5%), shortage of staff (67.6%), time constraints (66.2%), inadequate knowledge (54.4%), poor supervision (47.1%), high work load (44.1%), and not being a priority (33.8%). Moreover, through FGD and KII, four main barriers to oral care were identified namely; inadequacy of resources, knowledge gap in oral care practice, nurse related barriers (perception of nurses and initiative of nurses) and gaps in management.

CONCLUSIONS

The study concluded that nurses faced barriers at individual, organizational and ministry level that hindered them from performing standard and effective oral care. Therefore, there is a need for further training, motivation, standardized protocol and provision of equipment and supplies to promote oral health of patients.

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.

Pilot study for risk assessment of aspiration pneumonia based on oral bacteria levels and serum biomarkers

Background

Aspiration pneumonia is a serious problem among elderly patients; it is caused by many risk factors including dysphagia, poor oral hygiene, malnutrition, and sedative medications. The aim of this study was to define a convenient procedure to objectively evaluate the risk of aspiration pneumonia in the clinical setting.

Methods

This prospective study included an aspiration pneumonia (AP) group, a community-acquired pneumonia (CAP) group, and a control (Con) group (patients hospitalized for lung cancer chemotherapy). We used the Oral Health Assessment Tool (OHAT), which assesses oral hygiene, and evaluated performance status, body mass index, serum albumin levels, substance P values in plasma, and oral bacterial counts.

Results

The oral health as assessed by the OHAT of the aspiration pneumonia group was significantly impaired compared with that of the CAP group and the control (5.13 ± 0.18, 4.40 ± 0.26, 3.90 ± 0.22, respectively; p < 0.05). The oral bacterial count in the aspiration pneumonia group (7.20 ± 0.11) was significantly higher than that in the CAP group (6.89 ± 0.12), consistent with the OHAT scores. Oral bacterial count was significantly reduced by oral care.

Conclusions

OHAT and oral bacterial counts can be a tool to assess the requirement of taking oral care and other preventive procedures in patients at high risk of aspiration pneumonia.

The Effectiveness of Oral Care Guideline Implementation on Oral Health Status in Critically Ill Patients

Intubated patients need specific oral care due to the use of endotracheal tubes. An oral nursing care guideline needs to be implemented to guide nurses in oral care in intubated patients. To test the effectiveness of oral nursing care guideline implementation. The Rogers' Diffusion of Innovations Theory was used to introduce an oral nursing care guideline to 28 nurses working in an intensive care unit in a hospital within 2 months, using mass and private communication within a hospital management system. The oral care guideline was introduced to 47 intubated patients. The accuracy of oral care practice was assessed by nurse research assistants, and patients' oral health status was examined by dental nurse research assistants. The accuracy of practice among nurses was found between 88% and 100%. Total 97.47% (n = 46) of patients had an acceptable oral health status after receiving oral care based on the oral nursing care guideline. The oral nursing care guideline was effectively implemented with high accuracy and could increase patient oral integrity after its implementation.

Effects of different oral care scrubs on ventilator-associated pneumonia prevention for machinery ventilates patient: A protocol for systematic review, evidence mapping, and network meta-analysis

BACKGROUND

Ventilator-associated pneumonia (VAP) is defined as pneumonia develops in intensive care unit (ICU) patients who have been mechanically ventilated for at least 48 hours. Implementing effective oral car could reduce the incidence of VAP. However, previous studies on scrubs in oral care have failed to suggest which the best choice. Therefore, this protocol proposes to perform a network meta-analysis to evaluate the effectiveness of different oral care scrubs in preventing VAP.

METHODS

We are going to search the electronic databases: Cochrane Oral Health's Trials Register, CENTRAL, MEDLINE, EMBASE, CINAHL, and Chinese Biomedical Literature Database. Study selection and data collection will be performed independently by 2 reviewers. Cochrane Risk of Bias tool will be used to assess the risk of bias of included studies. Odds ratio (OR) and 95% confidence intervals (CIs) will be used to assess the incidence rate of VAP in critical patients. The evidence mapping (EM) method will be introduce as a tool intended to complement the conventional systematic review (SR) and is suitable for this issue, at the same time, R software will be used for representing the outcome of EM-SR. We shall assess the heterogeneity on the bias of the magnitude of heterogeneity variance parameter (I or Cochrane Q). We are also going to conduct subgroup analysis and sensitivity analysis if needed. The application of Stata and R software will be performed the calculations.

RESULTS

The results of this study will be submitted to a peer-reviewed journal for publication.

CONCLUSION

This network meta-analysis will provide comprehensive evidence of different scrubs in oral care for preventing VAP.

PROSPERO REGISTRATION NUMBER

CRD42018117019.

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.

Older people's perceptions of the quality of oral care in short-term care units: A cross-sectional study

BACKGROUND

There is a lack of knowledge about oral care among older people living in short-term care (STC) units and how the quality of oral care provided by nursing staff is perceived by the older people.

AIM

To (i) describe person-related conditions among older people in STC, (ii) describe and compare perceptions of the quality of oral care (including perceptions of care received and the subjective importance of such care), within and between older people who have the ability to perform oral self-care and those who are dependent on help with oral care and (iii) examine the relationship between person-related conditions and the quality of oral care.

METHODS

A cross-sectional study was conducted with 391 older people in STC units in Sweden based on self-reported questionnaire and clinical assessments.

RESULTS

The older people were assessed as having normal oral health (2%), moderate oral health problems (78%) or severe oral health problems (20%). When comparing older people's perceptions of quality of oral care in terms of perceived reality and subjective importance, significant differences appeared within and between groups. Psychological well-being had a significant relationship with perception of the quality of oral care (both perceived reality and subjective importance), and gender and oral health status had a significant relationship with subjective importance.

CONCLUSIONS

Older people's perceptions of areas for improvement regarding quality of oral care is a new and important knowledge for nursing staff in STC units. Older people want personalised information regarding oral health and oral care. Registered Nurses who take the responsibility in nursing care for older people's oral health may avoid unnecessary suffering by older people caused by oral health problems.

IMPLICATIONS FOR PRACTICE

Older people's perspective is an important component for quality work and might lead to improvements in the quality of oral care in STC.

Effect of Oral Care Program on Prevention of Ventilator-associated Pneumonia in Intensive Care Unit Patients: A Randomized Controlled Trial

Background:

Ventilator-associated pneumonia (VAP) is one of the most common nosocomial infections that increase mortality rate and the length of hospitalization. Oral care can improve patient's oral health, however, the role of oral care in the reduction in incidence rate of VAP is indisputable. The aim of this study was to investigate the effect of oral care on the frequency of VAP of patients in intensive care unit.

Materials and Methods:

This clinical trial was conducted on 80 participants who were randomly assigned to a control group and an intervention group from 2016 to 2017. Data were collected at the first, third, and fifth days of the study using a demographic and clinical characteristics questionnaire and the Clinical Pulmonary Infection Score for detecting pneumonia. Data analysis was performed using descriptive and inferential statistics in SPSS software.

Results:

The results of this study showed that the frequency of pneumonia on the third and fifth days was 15.80% (6) and 23.70% (9) in the control group and 10.50% (4) and 7.90% (3) in the intervention group, respectively. Chi-square test did not show a significant difference (p = 0.059); however, the frequency of pneumonia in the intervention group reduced compared with the control group.

Conclusions:

According to the results of this study, the oral care program could not significantly decrease the incidence of VAP in critically ill patients compared with routine oral care practices. Similar studies with a larger sample size and longer duration should be conducted for better results.

The Effects of Aloe vera-Peppermint (Veramin) Moisturizing Gel on Mouth Dryness and Oral Health among Patients Hospitalized in Intensive Care Units: A Triple-Blind Randomized Placebo-Controlled Trial

Objective:

Mouth dryness is one of the most prevalent problems in Intensive Care Units (ICUs). It facilitates dental plaque formation. The aim of this study was to analyze the effects of Aloe vera-Peppermint (Veramin) moisturizing gel on mouth dryness and oral health among patients hospitalized in ICUs.

Methods:

This triple-blind two-group randomized placebo-controlled clinical trial was undertaken in 2016–2017 on a convenient sample of 80 patients. Patients were randomly allocated to an intervention and a placebo group. Oral care for patients in the intervention and the placebo groups was provided for 5 successive days using Veramin moisturizing gel and a placebo gel, respectively. Data were collected at the 1^st, 3^rd, and 5^th days of the study using a demographic and clinical characteristics questionnaire, the Challacombe scale (for mouth dryness assessment), and the Mucosal-Plaque Index (for oral health assessment). The Chi-square, Fisher Exact, Mann–Whitney U, and Friedman tests were used for data analysis.

Findings:

In the 5^th day, the mean score of mouth dryness in the intervention group was significantly lower than the placebo group (P = 0.0001). On the other hand, in the third and the 5^th days, the oral health mean score in the intervention group was significantly lower than the placebo group (P = 0.0001).

Conclusion:

Veramin moisturizing gel is effective in significantly relieving mouth dryness, preventing dental plaque formation, and improving oral health. Thus, it can be used for improving oral care outcomes in ICUs.

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 effects of oral rinse with 0.2% and 2% chlorhexidine on oropharyngeal colonization and ventilator associated pneumonia in adults' intensive care units

BACKGROUND

Ventilator Associated Pneumonia (VAP) is the most common nosocomial infection in Intensive Care Units (ICUs) which increases the length of ICU stay, duration of mechanical ventilation, and mortality. The present study used an oral care protocol and compared the effects of two different concentrations of chlorhexidine on reduction of oropharyngeal colonization and VAP.

MATERIALS AND METHODS

This study was performed on 114 patients from trauma, surgery, neurosurgery, and general ICUs randomly allocated to two groups under oral care with 0.2% and 2% chlorhexidine solution. A multidisciplinary team approved the oral care protocol. Data was collected using a demographic information form, APACHE IV form, Beck oral assessment scale, mucosal-plaque assessment scale, and oropharyngeal swab culture.

RESULTS

The results showed a significant reduction in VAP (p=0.007) and oropharyngeal colonization (p=0.007) in the group under oral care with 2% chlorhexidine solution compared with the other group. However, no significant difference was found between the two groups in terms of oropharyngeal adverse effects (p=0.361).

CONCLUSION

Oral decontamination with 2% compared to 0.2% chlorhexidine is a more effective method in the prevention of VAP and reduction of oropharyngeal colonization (especially gram-positive).

Effects of simulation education on oral care practices - a randomized controlled trial

BACKGROUND

Implementation of evidence-based oral care protocols, nurse education programmes and assessment tools may reduce the risk of developing ventilator-associated pneumonia by increasing critical care nurses' knowledge and skills in adhering to current oral care recommendations.

AIMS

To evaluate the longitudinal effects of single-dose simulation education with structured debriefing and verbal feedback on critical care nurses' knowledge and skills in adhering to current oral care recommendations.

DESIGN

A randomized controlled trial with repeated measurements.

METHOD

The data for the study were collected in a single academic centre in a 22-bed adult, mixed, medical-surgical intensive care unit in Finland from February 2012 to March 2014. The effectiveness of simulation education was evaluated through the validated Ventilator Bundle Questionnaire and Observation Schedule at baseline (n = 30) and 24 months (n = 17) after simulation education. Data were analysed using a linear mixed model and intention-to-treat analyses.

RESULTS

During the study period, the average knowledge score in the intervention group increased significantly (44·0% to 56·0% of the total score) in the final post-intervention measurement (p_t  = 0·51, p_g  = 0·002, p_t*g  = 0·023). However, single-dose simulation education with structured debriefing and verbal feedback had no impact on critical care nurses' skill scores.

CONCLUSION

Single-dose simulation education had only a minimal effect on critical care nurses' knowledge and skills in adhering to current oral care recommendations. Despite increased awareness, there was no significant difference in oral care practices between the study groups after simulation education.

RELEVANCE FOR CLINICAL PRACTICE

The need for regularly repeated educational sessions with theoretical training and practical exercises and direct feedback is evident. Certain aspects of oral care, such as prevention of microaspiration of oropharyngeal secretions and moistening of oral mucosa and lips, require more reinforcement than others.