Oral Hygiene
Evidence Based Standards of Care
For The Dysphagic Patient
Stephen Fraser,
Speech-Language Pathologist
Dept . of Communication Disorders
St. Joseph’s Healthcare
Hamilton, Ontario
Today's Presentation
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Background information.
Current oral care practices in healthcare.
Implementation methods.
The Oral Care Standards.
Research at St. Josephs.
Components to Developing
Standards of Care
 Literature Review
 Consultation with other hospitals regarding
their standards
 Consultation with appropriate departments
(e.g.., pharmacy)
Why should hospitals care so
much about the oral cavity ?
Most bacterial nosocomial pneumonia are caused by
aspiration of bacteria colonizing the oropharynx or upper
GI tract of the patient.
Centres for Disease Control (1997)
Nosocomial pneumonia accounts for 10-15% of all
hospital acquired infections.
20-50% of all infected patients will die as a result of the
infection
J.Can.Dent.Assoc.(2002)
• Bacterial colonization of the oropharynx is an
important risk factor for VAP.
Muro (2004) American journal of critical care.
• Pathogens responsible for aspiration pneumonia were colonized in
the dental plaque of patients.
Scannapieco (1992) Critical Care Medicine
Why is Speech-Language Pathology
Addressing the issue of Oral Care?
Susan Langmore, Dysphagia (1998)
Susan Langmore, Dysphagia (2002)
How Does Aspiration Pneumonia
(including VAP) Occur?
ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM
IMMUNE SYSTEM
MUST HAVE ALL 3
When does Colonization occur?
Within 48 hours of admission to hospital
the oropharyngeal flora of critically ill
patients changes from
 the usual gram + streptococci and
dental pathogens to
 gram – organisms including Pathogens
that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
How do we stop this change in oral
pharyngeal flora?
 Mechanical Interventions (tooth
brushing)
 Use of pharmacological anti-microbial
agents (ex. Chlorhexidene)
 Combination Effect
American Journal of Critical Care ( 2004)
Oral Care Research
Treatment with oral hygiene alone,
reduced occurrence of pneumonia in
older adults in nursing homes by 30%
Yoneyama et.al. (2002)
Currently Reported
Oral Care Practices
Protocols for oral care measures are generally intended to
improve patient comfort, rather than removal of microbes.
AACN,Clinical Issues (1998)
Oral care procedures are not based on research evidence but
on tradition, anecdotal evidence and subjective assessments.
Nursing Standard (2001)
In a comprehensive review of evidence-based practice related
to strategies to prevent Aspiration Pneumonia in ventilator
dependent patients, Hixon et.al. noted that even though oral
hygiene is considered standard nursing care, it is often
neglected in critically ill patients or performed by quickly
swabbing the mouth.
AACN , Clinical Issues (1998)
Current Oral Care
Practices Continued…
Foam swabs are commonly used to provide
mouth care to patients who cannot provide
their own care.
SWABS ARE NOT EFFECTIVE FOR PLAQUE
REMOVAL AND ONLY PROVIDE MOISTURE
REFIEF.
Journal of Advanced Nursing (1996)
Nursing Times (1996)
However,
The foamstick is still the tool of
choice, for most critical care nurses.
Critical Care Nursing (1995)
Two Models of Implementation
(see Winter 2007 Communique Article)
Firstly, poster presentation on Evidence Based Practice Day.
Invited units to implement Oral Care Initiatives
ICU
Acute Care
(Including Stroke Unit)
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Standard Already Created. Told to
change anything but the key points
(Win Win Situation)
Worked with Nurse Manager and
Nurse Educator
Multiple in-services
Chose objective research measure
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Standard Already Created. Told to
change anything but the key points
(Win Win Situation)
Worked with nurse educator
Single in-service
Chose subjective measurement
Standards of Practice for Providing Oral
Care to The Dysphagic Patient
ICU Standard
 Applicable to ICU adult inpatients who are NPO,
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including ventilated patients.
RN provides oral care.
Oral assessment twice daily.
Document status of oral cavity in CareVue
( ex. Tooth colour, gum condition, odours).
Notify physician with any changes in oral cavity (ex.
Breakage of teeth, abscesses).
Use mouth swabs for moisture relief only.
Supplies
 1 SAGE package containing 2 toothbrushes
and perox-a-mint solution
 2-4 toothettes
 Chlorhexidene 0.12% oral rinse
 Disposable medical cups
 Suction source
 Yankauer suction handle
Procedure
Part A - Brushing
1.
2.
3.
4.
5.
6.
7.
Wash hands and put on gloves
Obtain 1 pkg. Sage – 6572 – c
Attach suction to toothbrush, moisten brush and
apply perox-a-mint solution
Brush patient’s teeth, gums, tongue, palate and
inside cheeks
Apply suction to cleansed areas
Rinse brush in water and repeat step 4-5
Soak dentures in denture solution
Procedure
Part B – Chlorhexidene 0.12%
1.
2.
3.
4.
5.
6.
7.
Check patient chart for allergies to chlorhexidene
Obtain doctor’s order for chlorhexidene
Place 15ml of chlorhexidene in medication cup
Soak toothette in chlorhexidene
Rub teeth, tongue, gums, and sides of mouth in
circular motion
Suction oral cavity and do not rinse
Apply oral moisturizer to lips
Procedure
 Document use of chlorhexidine in patient’s
cMAR and CareVue
 Use moistened toothettes every 2 hours
following brushing routine
 Moisten toothettes with water or water and 1.5%
hydrogen peroxide
Practice Alerts
 DO NOT add mouthwash or any medication to
chlorhexidine solution
 DO NOT administer Nystatin within 2 hours of
chlorhexidine use, as it renders Nystatin
ineffective
Acute Care
Standard
 Applicable to adult inpatients who are NPO, or are unable to
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have thin fluids.
Oral assessment OD.
Oral care prior to AM meal and post PM meal.
If NPO, oral care once on AM and PM shift
If NPO, moist swab every 2 hours for moisture relief. DOES
NOT CONSTITUTE ORAL CARE.
Patient in semi/high fowlers unless contraindicated.
SLP makes recommendation as part of assessment.
Supplies
 1 PLAK VAC oral evacuator brush.
 Toothpaste
 Suction source
 Yankauer suction handle
OR
 Chlorhexidene 0.12% oral rinse
 Mouthswab
Toothpaste – Why not?
 Canadian Dental Association (CDA)
regarding oral problems that would restrict a
person from using toothpaste to clean their
mouth. Other than allergy to a component,
CDA is not aware of any specific
contraindications for any particular patient
group. Kindly note, that individual patients
should consult with their dentist for specific
advice about oral care products in any given
situation.
Toothpaste – Why not?
 Trademark medical – no contraindication
regarding foaming in the suction line
(None found at St. Josephs)
 Informal Interview of SLP’s- some do not use
toothpaste, but no evidence based reasons
have yet been obtained
Procedure - Brushing
 Wash hands and put on gloves
 Obtain PLAC VAC BRUSH
 Attach suction to toothbrush, moisten toothbrush and
apply baking soda
 Brush patient’s teeth, gums, tongue, palate
and inside cheeks
 Apply suction to cleansed areas
 Rinse brush in water, repeat step 4-5
 Soak dentures in denture solution
Alternate Procedure
Chlorhexidene 0.12%
1.
2.
3.
4.
5.
Place 15ml of chlorhexidene in medication
cup
Soak toothette in chlorhexidene
Rub teeth, tongue, gums, and sides of
mouth in circular motion
Suction oral cavity and do not rinse
Apply oral moisturizer to lips
Procedure
 Continue with routine until patient is receiving
thin fluids.
 Use moistened toothettes (with water) every 2
hours following oral care
ICU Research
2.0 VAP Bundle Compliance
Percentage
100%
50%
0%
n
Ja
07
0
2
b
Fe
07
0
2
M
ar
07
0
2
pr
A
07
0
2
M
ay
07
0
2
n
Ju
07
0
2
l
Ju
07
0
2
ug
A
07
0
2
S
ep
07
0
2
ct
O
07
0
2
ov
N
07
0
2
ec
D
Month
Actual
Goal
07
0
2
n
Ja
08
0
2
b
Fe
08
0
2
M
ar
08
0
2
pr
A
08
0
2
M
ay
08
0
2
n
Ju
08
0
2
l
Ju
08
0
2
Ma
y2
00
6
Ju
n2
00
6
Ju
l2
00
6
Au
g2
00
6
Se
p2
00
6
Oc
t2
00
6
No
v2
00
6
De
c2
00
6
Ja
n2
00
7
Fe
b2
00
7
Ma
r2
00
7
Ap
r2
00
7
Ma
y2
00
7
Ju
ne
20
07
Ju
l2
00
7
Au
g2
00
7
Se
p2
00
7
Oc
t2
00
7
No
v2
00
7
De
c2
00
7
Ja
n2
00
8
Fe
b2
00
8
Ma
r2
00
8
Ap
r2
00
8
Ma
y2
00
8
Ju
ne
20
08
Ju
l2
00
8
VAP Rate per 1000 Ventilator Days
1.0 VAP Rate in ICU per 1000 Ventilator Days
60
50
40
Oral Care q12h
Implemented
30
10
Oral Care
Increased to q6h
20
1. Vent Circuit
Changed
2. HOB>30'
3. Oral Care
Education
Started
0
Month
Actual
Goal
Questions?
References
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Gaynor, E. (2001). A Rational for Oral Care. Nursing Standard 15(43): 33-36
Grap, M.J. (2003). Oral Care Interventions in Critical Care: Frequency and Documentation. American journal of
Critical Care, 12(2): 113-119
Langmore, S.E. et al. (1998) Predictors of Aspiration Pneumonia; How important is Dysphagia? Dysphagia 13: 6981
Langmore, S.E. et al. (2002) Predictors of Aspiration Pneumonia in Nursing Home Residents. Dysphagia 17: 298307
Marik, P. & Kaplan, D. (2003). Aspiration pneumonia and dysphagia in the elderly. Chest. 124(1):328-336.
McNeil. H. E. (2000). Biting back at poor oral hygiene. Intensive and Critical Care Nursing, 16: 367-372
Mojon, P. (2002) Oral health and respiratory infection. Journal of the Canadian Dental Association. 68(6):340-345.
Mojon, P. & Bourbeau, J. (2003). Respiratory infection: How important is oral health? Current Opinion in
Pulmonary Medicine. 9:166-170.
Okuda, K et al. (1998, Feb). The efficacy of antimicrobial mouth rinses in oral health care. The Bulletin of Tokyo
Dental College. 39(1):7-14
Perry, A.G. et. Al., Clinical Nursing Skills Techniques, Fifth edition (2002)
Shay, K. (2000) Denture Hygiene: A review and update. The Journal of Contemporary Dental Practice. 1(2):1-8.
Terpenning, M. et al. (2001). Aspiration pneumonia: Dental and oral risk factors in an older veteran population.
JAGS. 49:57-563.
Terpenning, M. & Shay, K. (2002). Oral Health is cost-effective to maintain but costly to ignore. Editorial in JAGS,
50:584-585.
Trieger, N. (2004), Oral Care in the Intensive Care Unit, American journal of Critical Care, 13(1): 24-33
Yoneyama, T et al. (2002). Oral care reduces pneumonia in older patients in nursing homes. JAGS. 50:430-433.