1. Intensive Care/High Dependency Stream
Mouth Care
Guideline
Intensive Care/High Dependency Stream
ICU Education Collaborative Group
August 2011
Reviewed November 2012

2. Why is Oral Health important in ICU??
Poor oral health may increase the risks of serious complications in Critically Ill Patients.
Ventilator associated pneumonia is a major source of morbidity and mortality in the ICU.
During periods of critical illness mouth care is sometimes relegated to a lower priority and often forgotten.
What are some of the barriers to proper oral care in ICU???
An intact oral mucosa, like our skin is an effective barrier to microbes
I thought of a few
Fear of dislodgement of ETT
Difficulty accessing the mouth due to ETT, securing tapes etc
Fear of aspiration
Fear of adding to patients discomfort
Nurse’s time constrants
Lack of training / knowledge of proper mouth care assessment and care
Perception that oral care has a low priority for critically ill patients.
Dry mouths may contribute to mucositis, accumulation of dental plaque and reduction in the salivary immune factors causing the oropharyngeal colonisation of Gram Negative bacteria

3. Why is Oral Health important in ICU??
Dental plaque provides a breeding ground for respiratory pathogens
A extracellular matrix
1mm3 of plaque contains about 100 million bacteria
A resistant layer microorganisms adheres tenaciously to teeth surfaces.
Potential association between pathogenic bacteria in the mouth with those identified in the lungs.
Healthy vs. ICU intubated pt
Mm3 – Cubic millimeters
Bacterial plaque builds upon teeth within 72hrs after cessation of oral care
In a healthy subject, the respiratory tract is able to defend against aspirated bacteria. Once intubated the natural barrier between the oropharynx and the trachea is compromised.
ICU intubated patients will have;
Diminished salivary flow cause there mouth is constantly opened & certain drugs they receive in ICU can cause XEROSTOMA
ETT interfere with the cough reflex and mucociliary clearance
Provides a direct conduit for rapid access of bacteria into the lower respiratory tract.
Inability to perform their own oral hygiene
Placing the patient at great jeopardy of developing VAP

4. Oropharynx Colonisation-Pneumonia Pathway
Here is a picture of how the oropharynx colonisation can cause VAP
Multiple bacteria types colonise the mouth, gums, tongue and teeth and are carried by oral secretions to the subglottic area above the ETT cuff.
Micro aspiration of these subglottic secretions occur through micro spaces formed between tracheal tissue and the ETT cuff.
Biofilms ( a thin resistant layer of microorganisms – Bacteria) attach to the surface of the ETT thus representing another mechanism by which the lung can be infected
Drainage of tubing condensation down the pt,s airway, suctioning, bronchoscopy or N/S instillation flush these biofilms into the lungs. .

5. Pathogenesis of VAP Exogenous microbes Endogenous microbes
More than one potential pathway for colonisation of the oropharynx and the trachea
Endogenously
A – Oropharyngeal colonisation ie Dental plaque
B – GI Colonisation, Stomach is a reservoir for pathogens - Increased gastric pH leads to bacterial overgrowth & reflux can lead to colonisation of subglottic oropharynx
Exogenously C-F after admission to the hospital , Patient care activities transmit pathogens when infection control practices are substandard ie, Patient to patient , Staff to patient,
Faecal – oral cross infection and contaminated equipment
Air , Water and food

6. What is the current rate of infection?
Reported mortality rates for VAP range from 24% to 50%
potential higher figures in immunocompromised patients or when multi-resistant organisms are involved.
Cost of VAP in the US;
A rise in the cost of care to $ US 10,000 – 40,000 per case.
With increased mechanical ventilation days & LOS
Difficult to study due to problems with diagnosis.
Both the JHH and CMN do NOT collect any VAP data.
A recent systematic review found that patient’s who acquired VAP spent an additional 5 to 7 days requiring ICU care.
Predicted to accrue 1.5 billion healthcare dollars annually.

7. Consequences of Poor Oral Hygiene
Xerostomia
Gingivitis
Mucositis
Periodontitis
Candidiasis
Halitosis 1. 2.
1. Xerostomia - Dryness of the mouth caused by reduced saliva secretion.
2. Gingivitis is inflammation of the gums in response to bacteria plaque on adjacent teeth.
3. Oral Mucositis is a painful inflammation and ulceration of the mucous membranes of the mouth, usually adverse effects of chemo and radiation therapy.
4. Periodontitis occurs when inflammation or infection of the gums is left untreated. Infection spreads from the gums to the ligaments and bone that support the teeth. Periodontal pockets develop between the gums and the teeth that often trap plaque causing tooth abscesses.
5. Candidiasis or thrush is a fungal infection (mycosis) of any of the Candida species of which Candida albicans is the most common.
6. Dental plaque is a biofilm, usually colourless, that develops naturally on the teeth. It is formed, as in any biofilm, by colonizing bacteria trying to attach itself to a smooth surface (of a tooth).
8. Halitosis - Offensive breath commonly caused by poor oral hygiene, dental or oral infections. 3. 4. 5.

8. Normal Oral Environment
Normal Oral Flora
Predominately Gram – positive streptococci and dental micro-organisms.
Functions of Saliva
Lubricates
Buffering Properties
Antimicrobial Properties
Immunoglobulin A which obstructs microbial adherence
Lactoferrin which inhibits bacterial infection
Fibronectin which blocks pathogenic bacterial attachment to oral mucous membranes
Lubricates
Washes food debris and unattached micro-organisms from the mouth.
Buffering Properties
Neutralises acids produced by bacteria on tooth surfaces
Antimicrobial Properties
Immunoglobulin A which obstructs microbial adherence
Lactoferrin which inhibits bacterial infection
Fibronectin which blocks pathogenic bacterial attachment to oral mucous membranes

9. During Critically Illness
The oral flora shifts dramatically to aerobic Gram – negative bacilli and staphylococcus aureus within 48hrs of admission.
Why??
More vulnerable for being colonised with exogenous microbes from the ICU environment .
Increased severity of illness and length of stay
Patients are on multiple medications causing salivary dysfunction and xerostomia
Constant opened mouth leading to dry mucus membranes.
Accumulation of dental plaque
A reduction in salivary immune factors such a Immunoglobulin A (IgA)
Increased levels of proteases in their oral secretions causing a
Depletion of fibronectin exposing tooth surfaces to the attachment of organisms, such as pseudomonas aeruginosa.
Exogenous – outside the body getting in
WHY
poor hand hygiene of health care workers & contaminated equipment
Increased severity of illness and LOS - the degree of colonisation with respiratory pathogens increases to more than 70%.( Pesola 2004)
Medications that cause Xerostoma
Antihypertensives
Inotropes
Anticholinergics
Antihistamines
Antipsychotics
Anticonvulsants
Diuretics
Antidepressants

10. Dental Plaque & Biofilms
If plaque is allowed to grow undisturbed
Bacterial adherence due to depletion of fibronectin
Colonisation of the mouth
Changes in oral flora
Micro aspiration of subglottic secretions.
Increase risk of developing VAP
If oral care is not started upon admission, the mouth could become colonised with harmful bacteria within the first 48hrs of admission

11. What has already been implemented to reduce VAP to date?
Ventilator BUNDLES
Guidelines
Head of bed elevation to 30 – 45 degrees
Daily ‘sedation vacations’ and assessment of readiness to wean
Peptic ulcer prophylaxis
DVT Prophylaxis
Oral care with Chlorhexidine
General
Ventilation minimisation
Closed in line suctioning
Weekly circuit changes
Hand hygiene
Specific
Prevention of aspiration
Subglottic suctioning
Deep pharyngeal suctioning
Reduce colonization of oropharyngeal tract
Prevent contamination of respiratory equipment
The Institute for Health Care Improvement and the Centers for Disease Control and Prevention developed a set of recommendations for intubated patients aimed to improve outcomes and to help reduce VAP. Oral care with CHX was added in 2007
Guidelines are also used in individual hospitals to prevent the incidence of VAP.
Subglottic suctioning – Additional lumen that ends above the cuff and connects to the external suction port
POW Hospital did a observational study looking at suctioning of subglottic secretions and noted 5mls /hr was suctioned.

12. HNEAH Mouth Care Guideline
Our aim is;
Maintain mouth moisture
Provide adequate salivary flow together with
Control of plaque formation*
Through
Mechanical cleansing with a tooth brush
Chemical cleansing with Chlorhexidine.
This is essential in the preservation of oral health and decreasing the risk for infections in susceptible patients

13. HNEAH Mouth Care Guideline
The HNEAH Guideline utilizes ;
Comprehensive mouth care assessment
Mouth care intervention plan
Twice daily brushing teeth, gums and tongue using a soft paediatric toothbrush
Application of 0.2% chlorhexidine gel
Stimulation of the oral mucosa hourly with a foam swab to promote salivary flow
Maintain lip moisturizing every 4 hours with white soft paraffin.

14. Mouth Care Assessment Tool
Category
Rating 1 2 3
Lips
Smooth and pink
Dry, cracked or chapped
Peeling, split, ulcerated or bleeding
Tongue
Pink, moist and papillae present
Coated or loss of papillae with shinny appearance with or without redness
Blistered or cracked, heavy coating, thrush or ulcerated
Saliva
Watery
Thick or ropy
Absent
Mucous Membranes
Pink and moist
Reddened or coated (increased whiteness) without ulcerations
Ulcerations with or without bleeding
Gingiva
Pink and firm
Oedematous with or without redness
Spontaneous bleeding or bleeding with pressure
Teeth or Dentures
(or denture bearing area)
Clean and no debris
Plaque or debris in localised areas
(between the teeth)
Plaque or debris generalized along gum line or denture bearing area

15. MCAT intervention plan
Score 6 – 8
No Oral Dysfunction
Ventilated
BD tooth brushing with chlorhexidine gel
2 -4th hourly mouth moisturising with water or water soluble mouth moisturiser
Daily MCAT
Non ventilated
BD tooth brushing with toothpaste
4th hourly mouth moisturising with water or water soluble mouth moisturiser
Score 9 – 12
Mild Oral Dysfunction
2nd hourly mouth moisturising with Sodium Bicarbonate swabs
BD tooth brushing with toothpaste
Score 13 – 18
Moderate to Severe
Oral Dysfunction
Consider medical review
(e.g. Ulcerated areas and thrush)
Notes
Changes have been made from low, medium, high risk to now
No Oral Dysfunction
Mild Oral Dysfunction
Moderate to Severe Dysfunction
Mouth moisturising has changed to 2nd hourly, except in no oral dysfunction (2 -4 hourly)
Moderate to severe oral dysfunction is now BD tooth brushing, not TDS
Note
Patients with mucositis require medical review. Chlorhexidine is replaced with Sodium Bicarbonate and bland rinses ( ie Cetylpyridium Chloride or 1.5% Hydrogen Peroxide).
For patients’ ventilated for greater than 14 days tooth brushing with Chlorhexidine gel should be reduced to once a day and replaced with tooth brushing with water or mouth moisteriser.

16. What is the Evidence say ???

17. Consensus – Based Clinical Guideline
Chlorhexidine and subglottic suctioning are the only A grade recommendations by ICCMU.
American Thoracic Society recommends the use of continuous aspiration of subglottic secretions to combat VAP – Level 1 recommendation.
But why don’t we use above the cuff suctioning???? COSTS

18. Tooth brushing
Dental plaque is a very thick biofilm and requires the mechanical action of cleaning with a toothbrush.
Mouthwashes alone will NOT eliminate dental plaque formation.
Biofilm protects bacteria against chemical agents such as chlorhexidine
Foam swabs do not remove plaque
Pearson (2006) showed the elimination of dental plaque was more effective using a toothbrush than foam swab.
Paediatric toothbrushes are recommended because it can reach all aspects of the mouth
Cautions are to be discussed in the following patients
Patients who are coagulopathic
Patients with platelets < 20 x 109L
Patients who have significant mouth ulceration or gross mucositis
Patients with already bleeding gums
Moderate to severe oral dysfunction is only BD tooth brushing not TDS as previous

19. Denture Care
NB: Remove partial or full dentures from a ventilated patient and do not reinsert until patient is extubated
For non-ventilated patients remove dentures prior to daily assessment as per Oral Hygiene Care HNELHD CP11_35
For all patients with dentures:
Clean the palate, teeth, gums and tongue with a soft toothbrush or mouth swab
Inspect oral cavity as per MCAT (irritated or broken areas may indicate a poor fitting denture)
If available use patient’s own denture tooth brush and toothpaste to clean dentures with warm water over a basin
Use only moderate pressure to prevent scratches
Rinse dentures thoroughly
Dentures should be stored, cleaned and labelled in a denture container filled with water to prevent dentures drying out, shrinking or changing shape. This water needs to be changed every 24hrs and the storage container cleaned regularly to prevent growth of microorganisms
To remove stains and hardened deposits, add warm water and denture cleaner (patient to supply)
Clean toothbrush thoroughly and store in a clean container separate from other personal hygiene products.
Note
Additional information regarding denture care, including cleaning and storage
Non ventilated patients should have their dentures removed daily for oral assessment

20. Chlorhexidine Gluconate (CHG)
Is an antiplaque agent with potent antimicrobial activity
CHG binds to oral surfaces and released over time
Chemically active on tissues for up to 6 – 12 hrs
BUT depends on adherence to CLEAN oral surfaces
Mechanical cleansing with toothbrush is recommended first.

21. Chlorhexidine What's The Evidence??
The evidence for the BEST solution is varied.
Two meta-analysis (Chan & Pineda) looking at CHG
reported that although CHG may reduce the incidence of VAP, it doesn’t reduce the time on the ventilator or lower mortality rates.
A study by DeRiso and colleagues(1996)
showed a reduced number of respiratory infections by 69% after applying CHG in post op cardiothoracic patients.

22. Chlorhexidine Gluconate (CHG)
A study by Tantipong and colleagues showed
That oral decontamination with a higher concentration of 2% CHG is more effective in preventing VAP than with a lower concentration.
9.8% of patients developed irritation of the oral mucosa.
Adverse effects
Discolouration of the teeth & tongue
Alterations in taste perception
Increase calculus formation

23. Sodium Bicarbonate Is an odour absorber & acid neutraliser
Dissolves mucus and loosen oral debris
Neutralises plaque acids and is a natural buffer
Breaks up plaque & inhibits the attachment to tooth surfaces.
Recommended for Mucositis
Sodium Bicarb has been shown to dissolve mucous, thus allowing saliva to perform more efficiently its function of removal of cellular debris and reduce acidity in the oral cavity. (Garcia 2005)

24. Moisturizers
A moisturizer should be used on the lips and inside the mouth to prevent drying and cracking
Petroleum – based moisturizers should be avoided because they cause inflammation if open wounds are present
Water – based moisturizers are preferred as such products are easily absorbed by the skin and provide additional hydration.
Notes
Mouth moisturiser can be used to lubricate the lips and inside the mouth using a plain oral swab including cheeks, gums and tongue
White soft paraffin can be used on the lips only

25. In Summary
In Summary
Comprehensive mouth care assessment with MCAT intervention plan
Twice daily brushing teeth, with chlorhexidine gel
Stimulation of the oral mucosa 2th hourly with a foam swab to promote salivary flow
Maintain lip moisturizing every 4 hours with water soluble gel.

26. References
Berry, A. Davidson, P., Masters, J., & Rolls, K. Systematic Literature Review of Oral Hygiene Practices for Intensive Care Patients Receiving Mechanical Ventilation. American Journal Of Critical Care, 2007; Vol 16, No6,
Berry, A ., Davidson, P., Masters, J., Rolls, K., & Ollerton, R. (2010) “Effects of Three Approaches to Standardized Oral Hygiene to Reduce Bacterial Colonisation and VAP in Mechanically Ventilated Patients: A Randomised Control Trial”, International Journal o Nursing Studies In print
Browne, J., Evans, D., Christmas, L., & Rodriguez, M. (2011) “Pursuing Excellence: Development of an Oral Hygiene Protocol for Mechanically Ventilated Patients”, Critical Care Nursing Quarterly , Vol 34, No 1, pp
Blot,S., Vandijck,D.,& Labeau, S. (2008) “Oral Care of Intubated Patients”, Clinical Pulmonary Medicine Vol.15, Number 3, pp
Garcia,R., (2005) “ A review of the possible role of oral and dental colonisation on the occurrence of health care – associated pneumonia: Underappreciated risk and a call for interventions” American Journal of Infection Control, Vol33, No9,pp 527 – 540.
Hutchins,K., Karras, G., Erwin, J., & Sullivan, K. (2008) “Ventilator – associated pneumonia and oral care : A successful quality improvement project”. American Journal of Infection Control, Vol37, No7, pp 590 – 597.
ICCMU Consensus-based Clinical Guideline for the Provision of Oral Care for theCritically Ill Adult intensivecare.hsnet.nsw.gov.au/five/doc/intensive%20care%20collaborative%20guidelines/8%20%20Final%20oral%20guideline%20December%205_1.pdf
Monro, C.L., Grap, M. Elswick, R. & McKinney,J, (2006) Oral Health Status and Development of Ventilated Associated Pneumonia: a descriptive study. American Journal Of Critical Care Vol15, No4, 453 – 460.
Paji, S., & Scannapieco, F. (2007) “Oral Biofilms, Periodontitis and Pulmonary Infections”. Oral Disease Journal, Vol 13, No6, pp
Pear, S. Oral Care is Critical Care: The Role of Oral Care in the Prevention of Hospital –Acquired Pneumonia. Infection Control Today, 2007; Vol11, No 10.
Safdar, N., Crnich, C., & maki, D. (2005) “ The Pathogenesis of Ventilator – Associated Pneumonia: Its relevance to Developing Effective Strategies for Prevention, Respiratory Care , Vol 50, No6, pp 725 – 741.
Stonecypher, K. (2010)” Ventilator – Associated Pneumonia: The Importance of Oral Care in Intubated Patients”, Critical Care Nursing Quarterly , Vol 33, No 4, pp 339 – 347.