ORAL CARE IN THE INTENSIVE CARE UNIT

Introduction

Oral Care is an important component of nursing in the Intensive Care Unit (ICU) but it is
often given low priority when compared with other clinical practices. In a recent survey of all
twenty-four ICUs across Scotland1, 100% respondents felt that oral hygiene was a
worthwhile use of time in the ventilated ICU patient but only 54% recognised its importance
in the prevention of Ventilator Associated Pneumonia (VAP). Last year there were 5284
admissions to Scottish ICUs and of these 145 patients (2.7%) developed a Ventilator
Associated Pneumonia.

VAP is pneumonia that develops 48 hours or longer after mechanical ventilation is given by
means of an endotracheal tube or tracheostomy. VAP results from the invasion of the lower
respiratory tract and lung parenchyma by microorganisms. Intubation compromises the
integrity of the oropharynx and trachea and allows oral and gastric secretions to enter the
lower airways. Aspiration of bacteria from the upper digestive tract is important in the
pathogenesis of this infection2. Recent evidence suggests that oral bacteria could be an
aetiological factor of VAP. Thus oral hygiene measures are not solely for patient comfort as
many medical staff assume3.

There are no published guidelines on oral hygiene practices for ventilated patients in
Intensive Care Units in the UK. However in 2008, the National Institute for Health and
Clinical Excellence (NICE) published recommendations that oral antiseptics such as
Chlorhexidine should be included as part of the oral hygiene regimen for all patients who are
intubated and receiving mechanical ventilation1 and in May 2010 the Institute for Healthcare
Improvement (IHI) added daily care with Chlorhexidine to its Ventilator Bundle4 following a
review of the abundance of literature largely supporting its role in reducing number of VAPs.

The Health Act 2006 Code of Practice requires NHS organisations to audit policies and
procedures to prevent infection. The Department of Health published a care bundle for
ventilated patients in June 2007 and one aspect was that routine oral hygiene should be
carried out as per local policy.

Hospital Protocol

The Protocol for Oral Hygiene in place within the hospital is reviewed annually. Its main aims
are to promote patient comfort, prevent accumulation of dental plaque and colonisation of
the oral mucosa. In addition, it specifically states that if followed, these measures can help to
prevent pneumonia.

The protocol recommends all patients are given their own bottle of chlorhexidine
mouthwash, a tube of chlorhexidine gel and a tube of oral balance on admission. It clearly
explains how to apply the chlorhexidine gel using a four-quadrant approach and encourages
sterility where possible. Plaque removal is recommended using a soft, paediatric toothbrush.
For ventilated patients, each bedside also has a Daily Mouthcare Chart which should be
updated when oral care has been performed. This is a concise chart with timings of when
oral care should be performed. It breaks the day into four sections: 6am, 12noon, 6pm and
10pm. It specifies that at each of these times, regular suctioning for the mouth and
oropharynx should be carried out both before and after tooth brushing and application of
chlorhexidine gel. In the morning, the use of oral balance or KY jelly is required to moisten
lips. It has additional tick boxes at the bottom for PRN use of oral balance or KY jelly,
cleaning of dentures and whether a dental referral should be considered.

Aims and objectives

The aims of this study are to review the currently applied oral hygiene (OH) protocol, assess
its effectiveness and staff compliance with the daily protocol. In addition we sought to
examine the oral microflora in all patients daily to identify any trends and observe the
epidemiology of VAP organisms, if any, and to evaluate the oral hygiene and flora in these
patients. We aimed to compare our results with current literature.

Method and patients

A daily oral hygiene (OH) assessment was undertaken of all ventilated and non-ventillated
patients and a standard audit proforma completed. This included details of the patients
illness, medications, demographics and the presence of any clinical oral disease. Diseases
specifically looked for were dental caries, plaque, gingivitis, anglular chelitis, xerostomia and

lesions of the soft tissues including lips. In ventilated patients, how many times the oral
hygiene was recorded as having been perfomed was also noted.
A swab of the oral cavity was taken daily and analysed by the consultant microbiologist.
All patients in ICU were included.

Results

15 patients were included in the study over a four week period. This did not include patients
who were admitted and discharged over the weekend.
There were eight males and seven females. The age range was 17-77 years with a mean
age of 53.5 years.

Of the 15 patients, 11 were ventilated during the time this study was being carried out.
Compliance with the oral hygiene protocol in ventilated patients was monitored.

Patient

Days

No times/day OH

No times/day OH

Compliance

was performed

(%)

observed required to be performed

1

16

13

81.25

17

16

94.12

24

15

62.5

13

10

76.92

18

44.44

13

52

45

86.54

12

70

32

21

65.63

16

14

87.5

10

50.0

11

75.0

Table 1. Compliance with Oral Hygiene protocol for ventilated patients.

The Overall compliance with the protocol for ventilated patients was 72.17%.

Oral care was always provided by the staff nurse.

An oral assessment was carried out for every patient each day for four weeks (excluding
weekends). Of 15 patients, two were found to be edentulous. Of the thirteen dentate
patients, four were found to have poor dental heath with retained roots and fractured teeth
present. One was found to have gingivitis which he had on admission and which resolved
over the proceeding three days.

Four patients had a dry, fissured tongue on at least one inspection and one had glossitis
present over three days. All of these patients were ventilated.

Of the fifteen patients, one had a nasotracheal tube in situ, four had endotracheal tubes
which had been present for three days or less and the remaining ten patients either had, or
previously had an endotracheal tube (ETT) in place for more than five days. Trauma to soft
tissues was very common amongst those intubated with an ETT and in the period following
extubation. All patients who had an ETT in situ for more than three days were found to have
traumatic lesions present at the commisure on the side to which the ETT was placed. The
patient with the nasotracheal tube did not have any traumatic lesions present. It was difficult
to establish if these lesions were truly angular stomatitis or simple trauma from the ribbon
used to hold the ETT in place. Three patients developed traumatic lesions on their lower lips
in the region the ETT ribbon was held, one patient developed a traumatic lesion on the chin,
and another two developed significant trauma to the inner aspect of the lower lip from the
adjacent lower teeth in the region of the ETT ribbon, and subsequently developed ulcers
which had an apthous appearance.

Xerostomia was present in one patient and this was being remedied with frequent sips of
water.

Plaque on the teeth was noted in five patients on at least one occasion. However as the
daily oral assessment was carried out at a random time each day, this does not have any
significance as it may have just been prior to the oral care being carried out. The rate of
gingivitis was extremely low (1 in 15 patients) suggesting plaque removal was adequate. It
was noted that on the occasions plaque was present, it did not necessarily correspond with
the side of the mouth the ETT was in, thus it did not appear the ETT was responsible for
limiting access to that side of the mouth.

There was an overall improvement in the oral hygiene in patients admitted to the ICU from
admission to discharge, with most of the plaque and gingivitis being recorded in the first
three days of the admission.

Swabs were taken intra-orally from all patients over a three week period in order to assess
for any trends in the oral microflora. All patients who had a swab taken were found to have
candida albicans on at least one culture. One revealed Serrata Marcescens on day 7,
another had a Coagulase Negative Staphylococci on day 6, three patients had grown
Enterococcus Faecalis on at least two swabs, all of which were after day two of their
admission. One patient was found to have Klebsiella Pneumoniae on admission and another
had Proteus Mirabilis along with Klebsiella Oxytoca on days 5 and 6.

There were no cases of VAP whilst this study was being carried out.

Discussion

Pneumonia is the most common nosocomial infection in intensive care units and significantly
contributes to morbidity patterns and mortality among mechanically ventilated patients5. It is
also associated with prolonged ICU stay and increased cost2,6. 9-28% of patients treated
with mechanical ventilation will acquire VAP, and 24-50% of these will be fatal7. These
figures can be higher in immunocompromised patients or when pneumonia is caused by
multiresistant pathogens5. VAP occurs when normal pulmonary defence systems are
impaired or overwhelmed8. Upper respiratory tract flora play an important role in preventing
infective microorganisms reaching the alveoli, but in ICU patients, changes to the
commensal population means gram negative organisms predominate. These orgainisms
pool above the dynamic cuff of the ETT and this leads to aspiration. Micro-aspiration of
oropharyngeal secretions is well recognised as a significant risk factor in the development of
VAP9,10. Having an ETT in situ means normal coughing and swallowing reflexes and tracheal
protection by epiglottis closure are all lost.

ICU patients are thought to be at an increased risk of VAP due to decreased levels of
consciousness, a dry open mouth and microaspiration of secretions. Evidence has shown
that there is a change in the oral microflora in patients in the intensive care unit. Typical oral
microflora include Streptococcus, Staphylococcus, Actinomyces and Eubacterium. After 24
hours, this has been found to alter to pathogenic bacteria such as Pseudomonas,
Acinetobacter and Methicillin Resistant Staph Aureus3.

Candida albicans is found in approximately 35% of the general population, but the incidence
is increased in those who wear dentures and hospitalised patients11. Antibiotics are known to

predispose to Candidal infection by inhibiting the commensal bacteria antagonistic to

Candida thus increasing the numbers of microorganisms present. As all of the patients in the
study were on Antibiotics this goes some way to explaining the high rate of Candida cultured
from the microbiology swabs. The presence of Enterococcus Faecalis is not entirely
surprising either as its presence in teeth with root canal treatment has been demonstrated in
the past12, yet it would not be considered a normal oral commensal. The Klebsiella species
can be considered normal oral pathogens and are often involved in nosocomial infection.
Proteus Mirabilis is a gram negative facultative anaerobe commonly found in wound
infections, sepsis and pneumonias. Thus the results obtained from the microbiology swabs
reflect current literature in that the microflora of our patients changed over time in the ICU to
become more gram negative and anaerobic.

Angular Chelitis has a multifactorial aetiology including trauma, Candida infection and skin
creasing with saliva leakage and maceration at the angles of the mouth. Clinically it can
present with features of small areas of inflammation or it can result in extensive ulceration
and crusting. Typically yellow crusting suggests involvement of Staph Aureus but other
microorganisms can be implicated such as Candida and Beta-haemolytic Streptococci. The
symptoms are generally mild however there is the possibility of chronic nose-mouth transfer
of staphylococci and contamination of wounds. The results from show the majority of
patients appear to have sustained lesions similar in appearance to Angular Chelitis. It is not
unreasonable to treat these conservatively initially but if they fail to resolve, Miconazole gel
which has both antifungal and antistaphylococcal activity, is effective treatment.

Saliva production is generally decreased in ICU patients due to a number of factors. Many
drugs can cause a dry mouth (xerostomia), some of the interventions in the ICU could affect
the oral cavity- unhumidified oxygen therapy administered by a facemask can dry the mouth,
intermittent suctioning carries a potential risk of causing damage to oral tissues, restricted
oral intake can cause dehydration and anaesthesia itself reduces oral secretions.
Xerostomia can be induced by a whole host of medications such as those with
antimuscarinic side-effects eg tricyclic antidepressants, anti-spasmodics and some antipsychotics, it can be caused by diuretics, chemotherapeutic agents and anti-hypertensives.
These are common drugs in the ICU setting and all the patients in the study were taking at
least one.

The effects of reduced salivary flow lead to a reduction in immune defences normally
conferred by saliva. Saliva has many antibacterial components such as Immunoglobulin A
which obstructs microbial adherence in the oral cavity and Lactoferrin which is known to

inhibit bacterial infection by binding to the lipopolysaccharide component of bacterial walls

affecting the membrane permeability and resulting in lysis of bacteria. Saliva also has a
flushing effect on plaque reducing the likelihood of it adhering to the tooth and it also acts as
a buffer maintaining the pH of the oral cavity within the optimal range of 6.5-7.5 to prevent
enamel erosion and dental decay.

Xerostomia can lead to tissue inflammation and mucositis which are uncomfortable for the
patient. Chapped lips and oral lesions provide areas for microorganisms to proliferate. A dry
mouth also causes an increase in oral protease which starts to digest fibronecin- a
glycoprotein that coats the oropharynx- allowing pathogens to attach. It is therefore
imperative xerostomia is avoided in the patients in the ICU, although achieving this is no
mean feat. Regular use of a lubricant to keep the perioral tissues moist thus reducing
reservoirs which may harbour bacteria is also recommended and is part of the protocol.

The current ICU protocol is set out for all nursing staff at induction. On admission every
patient follows the set protocol. Oral hygiene should be carried out with a soft paediatric
toothbrush to gain maximum access and non-foaming toothpaste three times daily. Evidence
has shown that oral care should be performed with a toothbrush rather than a foam swab, as
was common practice in the past13,14,15 in order to effectively remove plaque which is the
main source of bacteria in the oral cavity. This audit revealed over 70% compliance with this
policy and the improvement in oral hygiene seen in the patients suggests excellent
technique.

In addition chlorhexidine gel or mouthwash should be used. A meta-analysis by Chan et al in

200716 demonstrated that the use of an anti-septic mouthwash correlated with a significant
reduction in VAP but failed to show any differences in other end points such as mortality,
duration of mechanical ventilation or length of stay in ICU. Chlorhexidine acts as an
antiplaque agent- it has a positive charge at either end and binds readily to the negatively
charged enamel pellicle, mucosal cells and bacterial cell wall structures. Once bound, it can
exert its antimicrobial effect by damaging the microbial cell membrane and precipitating the
cell contents. It also inhibits microbial adherence since it is able to attach to a surface and is
slowly released thus maintaining its antimicrobial activity. Thus the inclusion of chlorhexidine
in the oral hygiene protocol is evidence based and this unit is 100% compliant. Its inclusion
in the daily goals serves as a reminder and means it is never overlooked.

It has also been shown that carrying out timed oral hygiene with VAP bundle showed
significant reduction in the number of VAPs when compared to those using the VAP bundle
alone3. This is also carried out within in this unit.

Thus the oral care protocol within the ICU is evidence based and the results have shown it to
be effective. The low incidence of ginigivits suggests that the mouth care is excellent as the
presence of plaque for more than 24 hours will generally induce inflamed gingival tissues.
Indeed oral hygiene was seen to improve for most patients between admission and
discharge- a credit to the protocol, training and diligence of the nurses and the team.

It is unrealistic to imagine all pathogenic bacteria can be eradicated from the patients oral
cavity, but by minimising the bacterial load present through good oral hygiene, topical
antiseptic agents and maintaining healthy perioral tissues, it has been shown that rates of
VAP can be reduced.

The results do highlight increased levels of trauma associated with ETT ribbons. Traumatic
lesions were most commonly found where the ribbon is tied at the commisure of the mouth,
and where it crosses the lower lip. This would suggest a new method of stabilising the ETT
should be sought. Indeed a trial of new devices is about to be implemented.

Local health care policy should be research or evidence based. The protocol assessed in
this study is evidence based, and has been shown to be effective.

Thus ICU patients are at a high risk of many oral conditions due to the drugs they are taking,
reduced salivary flow and the inevitable change in the oral microflora. There is an
abundance of literature to support the association between oral bacteria and the
development of ventilator-associated pneumonia. Thus it is essential oral hygiene protocols
are in place and correctly followed. This study has shown within this particular ICU, staff
compliance with the protocol is high and this is reflected in the low rates of VAP.

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