Best Practices in Oral Care

Q: What does current evidence tell us about best practices in oral care?A: Barbara Quinn, DNP, MSN, ACNS-BC, replies: Oral care, or oral hygiene, is the practice of keeping the mouth, teeth, and gums clean and in good health.1 Oral care has been promoted for more than 5000 years, although specific practices have varied across cultures and time periods. There is evidence of innovative oral care practices as early as 7000 BC, with later tools including toothpicks made of gold in Mesopotamia, toothbrushes made of chewing sticks in Babylonia, toothpaste containing ashes and eggshells in Egypt, and salt and vinegar mouth rinses recommended by Hippocrates.2 Although the products and practices involved may have changed, humans everywhere benefit from deliberate, evidence-based oral hygiene.3Although oral care is known to prevent cavities, it can also reduce the risk of pneumonia in hospitalized patients. Oral pathogens have been directly implicated in health care–associated pneumonia (HAP),4 which is the most common health care–associated infection in the United States and in intensive care units (ICUs) worldwide.5,6 Most pneumonia pathogens originate in the oropharyngeal cavity, colonizing and proliferating rapidly.4 These pathogens are passed into the lungs and saliva through macro- or micro-aspiration events, causing inflammation and infection in susceptible hosts.4,7Oral care is an essential practice to prevent HAP, as officially recognized in a recent expert guidance document resulting from the collaboration of several national organizations focused on infection prevention.8 Oral care interrupts the formation of the oral biofilm and reduces the pathogenic burden. Reducing or eliminating the pathogen, also called source control, halts a potential infection before it can begin.9 Delivering oral hygiene to patients is a commonsense, low-cost, low-risk intervention to prevent HAP, whether it is associated or not associated with mechanical ventilation.4,10Because much of the literature on oral care pertains to adults, this article will identify the most up-to-date evidence, guidelines, and practice recommendations regarding oral care for acutely and critically ill hospitalized adults.Oral care is essential for all patients, and an assessment to determine baseline oral health is an important first step. Poor oral health before hospital admission has been shown to increase the risk of pneumonia.11 Thus, addressing severe periodontitis and tooth decay and initiating appropriate treatment may reduce the risk of pneumonia. Oral health assessment tools that are commonly used in ICUs are listed in Table 1.Health care professionals must be provided with the tools they need to be successful. Evidence-based oral care requires high-quality equipment, and the investment in approved products is an important aspect of a hospital’s oral care program.16 We still have much to learn about the safest and most effective oral care products for hospitalized patients.17 The selection of products is based on professional dental literature and current oral care guidelines for hospitalized patients and may need to be adjusted for special needs, such as age and ability.18Mechanical products are intended to physically disrupt the stubborn oral biofilm that resists a swish-and-rinse method of cleansing.7 Soft bristles remove plaque from the surfaces of the teeth, gums, tongue, and hard palate.3 Manual tooth brushing is as effective as the use of powered toothbrushes.19,20 Although interdental cleaning is strongly recommended to remove debris and biofilm from between teeth,21 no studies have been reported in the literature on the use of interdental cleaning products to prevent HAP. Hospitals may choose to add interdental cleaning products to the standard oral care kit for patients who are responsible for their own oral hygiene.Swabs are beneficial for applying moisture but may not be a substitute for brushing. When it comes to removing biofilm from the mouth, high-quality brushing has been found to be more effective than using a foam swab.22 However, Marino et al23 found no difference in effectiveness between brushing and swabbing in patients receiving mechanical ventilation, which may indicate that the presence of an endotracheal tube makes thorough oral care more difficult regardless of the instrument used.Suction toothbrushes may be beneficial for acutely ill patients at risk for aspiration and are cited in critical care literature.24 These devices allow the clinician to brush and clean the mouth while maintaining suction to prevent aspiration of debris and secretions. Patients outside of the ICU who are at risk for aspiration may also benefit from use of a suction toothbrush.Toothpaste and other mild products are designed to be used in conjunction with a toothbrush to help achieve healthy teeth and gums.3 Common active ingredients in toothpaste include fluoride for cavity prevention, abrasives such as calcium bicarbonate, and surfactants to clean teeth. The American Dental Association (ADA) recommends using toothpaste with the ADA Seal of Acceptance to ensure effectiveness and safety.25For acutely ill patients with impaired swallowing or extremely dry mouth or who are receiving mechanical ventilation, the consistency of toothpaste may not be safe or comfortable. The chapter on oral care in the AACN Procedure Manual for High Acuity, Progressive, and Critical Care includes mention of an “oral solution,”24 which may be easier to use and to suction in these patients.Antiseptic rinse is recommended by the ADA for adults and children over the age of 6 for additional cleaning where the toothbrush will not reach. Mouth rinse should not be used as a substitute for mechanical brushing. Mouth rinse with therapeutic properties reduces the volume of bacteria and contains active ingredients such as chlorhexidine, cetylpyridinium chloride, or essential oils. Antiseptic rinse should be alcohol-free to prevent drying of the mouth and should have the ADA Seal of Acceptance, if possible.26Oral chlorhexidine is no longer recommended by the Society for Healthcare Epidemiology as part of routine oral care for hospitalized patients, including those receiving mechanical ventilation, as systematic reviews of randomized controlled trials indicate that it may increase mortality rates.8 A chlorhexidine de-adoption study showed that omitting oral chlorhexidine did not worsen patient outcomes.27Mouth moisturizer should be a component of a comprehensive oral care program. Xerostomia, or dry mouth, is a common patient complaint, and intense thirst is among the 10 most distressing symptoms of ICU patients.28 Brushing the teeth twice a day helps relieve dry mouth, and the ADA suggests the use of oral moisturizers such as saliva substitutes as a safe way to temporarily relieve discomfort between brushings.29 Applying cold water to the mouth via swab or spray, in addition to the use of menthol lip balm, was found to be effective in one pre-post study.30The use of lemon-glycerin swabs to relieve dry mouth is no longer recommended, and these items should be removed from oral care kits for acute and critical care patients. The lemon reduces the pH in the mouth, further drying oral mucosa and worsening xerostomia, and can damage tooth enamel over time.31,32No high-level studies have indicated the optimal frequency of oral care for hospitalized patients, resulting in reliance on guidelines and expert opinions. The ADA has long recommended brushing twice a day for 2 minutes as the standard for healthy adults and children to prevent tooth decay.3 In vulnerable patients, however, the suggested frequency might be based on the oral pathogenic replication rate, which must be addressed to reduce the risk of pneumonia. Walter Loesche, a research scientist at the University of Michigan, has hypothesized that oral pathogens replicate 5 times every 24 hours,33 which would require that oral care be performed 4 or 5 times daily just to keep up. Current practice varies, and ongoing research is required.Recommendations for the frequency of toothbrushing in adult patients not receiving mechanical ventilation vary from 1 to 4 times per day.8,24,34 For adults receiving mechanical ventilation, the recommended frequency varies from once a day to every 4 hours.8,24,34 Nurses should adhere to their organizational policy while taking into account differences in patient risk and need.The absence of teeth does not eliminate the need for oral care. Biofilm continues to grow on soft tissues, requiring regular brushing of the gums, tongue, and other oral tissues twice daily to remove food particles and bacteria.35,36 To further reduce the volume of bacteria, use of an antimicrobial mouth rinse after brushing may be beneficial.37Dentures worn by edentulate patients should be cleaned regularly. Like natural teeth, dentures also collect biofilm38 and can act as a reservoir for pathogens that can cause pneumonia.39 Instructions on denture care are shown in Table 2.According to current evidence and guidelines, including a recent notice from The Joint Commission,40 oral care is an essential element of standard patient care and should be delivered to all acutely and critically ill patients to prevent harm due to pneumonia. Dental experts and researchers support the importance of an oral assessment to identify individual needs. Hospitals must provide high-quality oral care products to ensure that clinicians have the tools they need to deliver preventive care, including soft-bristled toothbrushes, toothpaste or gel, alcohol-free antiseptic rinse, mouth moisturizer if needed, and denture care items. After all these years, oral care remains a low-cost, low-risk intervention to keep patients safe while in our care.