Oral Care: State of the Science

1. Oral Care: State of the Science Vicki J. Spuhler RN MS Nurse Manager RICU LDS Hospital

2. Ventilator Associated Pneumonia • In the US nosocomial pneumonia ranks 2nd in morbidity and 1st in mortality among nosocomial infections. • Adds 5-7 days to a hospital stay • Occurs in 9-24% of patients who are on ventilators • Reported mortality of 54-71%

3. Impact of Oral Health • Oropharyngeal colonization impacts • Cardiovascular disease • COPD • Endocarditis • Bacteremia • Important risk factor for Ventilator Associated Pneumonia

4. “Bacterial colonization of the oropharynx with S aureus, S pneumoniae, or gram-negative rods is positiviely associated with the occurance of nosocomial pneumonia” Craven,DE, Driks MR, Semin in Resp. Infect. 1987.

5. Saliva- What’s that got to do with it anyway? • Role of Saliva • Provides significant antimicrobial activity for the oropharynx • Contains a variety of specific innate and specific immune components • Saliva flow is stimulated by eating- chewing • Unstimulated flow .25-.35 ml/min • Stimulated flow increases 4-6 ml/ min

6. Role of Saliva • Decrease flow or lack of salivary secretion can lead to changes in oropharyngeal colonization • Teeth become more adherent to bacteria • Antimicrobial effects of saliva are absent • Oropharyngeal colonization takes place

7. Impact of ICU Environment • Xerostomia- chronic dry mouth • Reduces the mouths defense mechanism • Cause by tubes that transverse the oral cavity • Stress and anxiety reduces slaivary stimulation • Dehydration

8. Impact of ICU Environment • Within 48 hours of hospital admission oropharyngeal flora of critically ill patients undergoes a change to predominantly gram negative organisms. • High colonization of MRSA and Pseudomonas on dental plaque of patients in the ICU.

9. A reduction of microorganisms in the mouth decreases the pool of organisms available for translocation to and colonization of the lungs.

10. Improving Health Care Performance • Know what works • Use what works • Do well what works Don Berwick President CEO Institute for Healthcare Improvement

11. Evidence in Literature • Definitive scientific studies relating oral care interventions to VAP have not yet been published • Evidence based protocols are not available in the literature

12. Do we know what works? • Two ways exists to remove dental plaque and associated microbes: • Mechanical interventions • Pharmacological interventions with antimicrobial agents

13. Mechanical Interventions • Oral care practices are poorly defined in the literature • Rarely defines a mechanical component • Generally targeted at comfort • Surveys of nurses suggest that where practice is defined it is inconsistent at best

14. “ICU nurses mean rating of the priority of oral care was 53.9 on a 100 point scale” Johnson WG etal American Rev. of Resp. Dis. 1988

15. Impact on Nursing Barriers to providing oral care: • Concern about tube dislodgement • Limited access to oral cavity- tubes • Potential for the development of Bacteremia • Low priority • Time consuming • Requires little skill- “I didn’t go into the ICU to do oral care”

16. In a study of 66 patients receiving mechanical ventilation the routine oral comfort care provided by nurses was not associated with a reduction in either dental plaque or VAP. Munro C. Am J of Critical Care 2002

17. Oral Care Practices Foam swabs- stimulates mucosal tissue but is ineffective in removing plaque- used for intubated patients 91.5% of the time H202- removes debris but unless diluted can cause superficial burns to the mucosa Lemon-glycerin swabs- stimulates saliva initially but are acidic and cause irritation and decalcification of teeth causing rebound xerostomia

18. Oral Care Practices • Toothbrush- best mechanical intervention for removal of plaque • Currently no literature that demonstrates the relationship of the intervention to quantity or type of oropharyngeal flora or to the development of VAP. • Not without risk- potential to increase translocation of organisms from the oral cavity to trachea or blood if not effectively removed from the oral cavity.

19. Pharmacologic Interventions • Removal of microorganisms via oral topical bactericidal agents. • Tobramyacin study-1997- Abele-Horn et al • 58 of 88 mechanically ventilated patients treated with topical tobramyacin • Decreased incidence of VAP from gram-negative pathogens • Overgrowth of S aureus occurred • No incidence of resistance developed

20. Pharmacologic Interventions • Selective decontamination with polymixinB sulfate, neomyacin and vancomycin in double blind, placebo controlled trial on 52 mechanical ventilated patients (Pugin et al) • Decreased tracheobronchial colonization by microorganisms that can cause VAP • No change in mortality

21. Pharmacologic Interventions • Chlorhexidine .12% (Peridex) • Broad spectrum antibacterial agent • Bactericidal for gram-positive and gram-negative organisms • Used for patient suffering from gingivitis • No known microbial resistance has ever been demonstrated • Not absorbed through skin or mucous membranes

22. Chlorhexidine • Rare allergic reactions • Side effects minimal • Discoloration of teeth and tongue • Transient alterations in taste

23. Evidence for use of Chlorhexidine • 2 studies in elective cardiac surgery patients • DeRiso- double blind, placebo controlled • “rate of respiratory tract infections was lower in patients who received chlorhexidine than in those who received placebo” 17 of 180 vs 5 of 173 p=.05 • CHEST 1996

24. Evidence for use of Chlorhexidine • Houston et al- randomized placebo controlled study of same population of patients • “number of patients who had nosocomial pneumonia was lower in patients who received Chlorhexidine than in patients who received placebo.” • 4 of 270 vs 9 of 291 p=.21 • Subset of patients- those on mechanical ventilation for greater than 24 hours • 2 of 10 developed VAP vs 7 of 10 in placebo group

25. Limitations • Application to other ICU settings • In both studies treatment started prior to intubation • Long term effects of Chlorhexidine is unknown

26. Sub-glottic suctioning as adjunct to Oral care • Et tubes – VAP connection • Impair cough reflex • Alter normal flora of oropharynx • Pooling of secretions above the cuff of ET tube • Valles J- et al Annals of Int. Med 1995- • Kollef MH- et al CHEST 1999 • Mahul P, et al 1992 Intensive Care Medicine • demonstrated a reduction in VAP related to continuous sub-glottic suctioning

27. Sub-glottic suctioning as adjunct to Oral care • ET tubes designed for sub-glottic suctioning were developed. • Clogging of tube • Cost • Frequent adjustment of tube required • Use of CSS-ET tubes has been limited • Further studies required to demonstrate effectiveness

28. Summary • Oral care- significant intervention for ventilator patients • Best performed in the form of a protocol or clearly defined standard • Must include a mechanical component such as use of toothbrush to assure elimination of dental plaque- recommendation is Q12 hours • Oropharynx cleansing and mouth moisturizers should be applied Q4 hours • Use of topical antimicrobial should be considered • More evidence needed to support CSS-ET tubes • Effectiveness • Tube design • Cost