Inside the Current Issue
|
||
|
Cover Story War games from the storm fronts of disaster readiness |
||
| Newswire | ||
 |
||
| Purchasing Connection | ||
| Resources | ||
| Show Calendar | ||
 |
||
| Classifieds | ||
| Issue Archives | ||
| Advertise | ||
| About Us | Home | |
| Subscribe | ||
| Special Event Photos | ||
|
KSR Publishing, Inc. Copyright © 2008 |
||
 |
|
People, Places, Processes & Products that Influence the Supply Chain |
|
INSIDE THE CURRENT ISSUE |
|||
|
Infection Protection |
Connect with this month's featured Advertisers: |
||
|
Comprehensive oral care: by Karen J. Ridley, RDH, MS and Suzanne M. Pear, RN, PhD, CIC W hy does ventilator-associated pneumonia (VAP) remain a concern when most VAP prevention bundles include a comprehensive protocol for twice daily dental plaque removal in the intubated patient? First of all, performing oral care, even on oneself, can be challenging. Most persons, when seen for routine dental care, demonstrate residual plaque, particularly in less accessible areas. Performing oral care for another person is far more difficult. Nurses, the primary oral care providers for hospitalized and ventilated patients, may not have received hands-on instruction in performing plaque removal.1,2 Secondly, the selection of oral hygiene devices available in some hospitals may be limited and inadequate. This article, the second of a two-part series, will provide detailed instruction on the essential techniques and tools of comprehensive oral care.Toothbrushing
Toothbrushes must be soft enough to allow cleansing of the gingival sulcus, the shallow crevice between the gum tissue and the tooth. Additionally, for the ventilator-dependant patient, the toothbrush should be pediatric size because the endotracheal and orogastric tubes further limit access, especially to lingual tooth surfaces and the tongue. Using a suction toothbrush or continuously suctioning allows the oral care provider to continuously clear the oral cavity, preventing aspiration of bacteria-laden fluid which accumulates during brushing. With the patient’s head elevated at least 30º, the provider inserts the toothbrush to the most posterior part of the maxillary mucobuccal fold where upper teeth, gums and cheek tissues join. The toothbrush should be used dry or moistened with water rather than toothpaste to minimize impaired visualization. The use of an alcohol-free antibacterial mouth rinse is optional. The bristles of the brush are gently angled into the gingival sulcus and the brush is moved in a series of about 10 small circles. During this time, the brush is repeatedly debriding the same small area of plaque. The brush is then brought forward one or two teeth and the process is repeated until the entire mouth, all the tooth surfaces, both buccal and when possible lingual, have been cleaned. The gums, tongue and buccal membranes of the edentulous patient should also receive similar care. During tooth and mouth brushing, rinse the brush vigorously in water throughout the process to remove debris which accumulates on the bristles. When patients are uncooperative or are unable to hold the mouth open for cleaning the lingual and palatal surfaces, the use of a commercial mouth prop may be helpful. A makeshift alternative is to tape three to four tongue depressors in a stack with surgical tape, slip this wedge between the teeth, and then turn it on its side, to separate the jaws and allow for oral care provision. Care must be taken not to put fingers between the jaws of the uncooperative patient, as jaw motions are strong and severe injury may occur. Sponge cleaners Sponge cleaners are beneficial for application of antimicrobial agents to the gingival and mucosal tissues and or moistened with water or water-based moisturizer to keep the mouth hydrated. However, sponge cleaners should not be used for plaque removal from the tooth surface as studies have shown that these devices are effective only for removal of gross or bulk deposits. They cannot remove plaque from the gingival sulcus or the margins of crowns and restorations.3,4
Antimicrobials Current data suggests that the most effective mouth rinse for reducing plaque and gingivitis is 0.12% chlorhexidine gluconate (CHG).5 It is a cationic surface-active agent with substantivity—meaning it absorbs into soft and hard tissues and is released over time in active form. The new alcohol-free formulation minimizes dryness of the oral tissues and the risk for candida. The benefit of CHG rinse for VAP prevention has been questioned because of conflicting results of two recent meta-analyses.7,8 Explanations include the inability of 0.12% CHG to fully penetrate oral biofilm or to control multidrug-resistant and gram-negative bacteria.9 Considering these data, it would seem that at best, CHG mouth rinse should be used as an adjunct to mechanical plaque removal with a toothbrush, as opposed to replacing this essential component of comprehensive oral care.10 Half-strength hydrogen peroxide (1.5%) is also used as an oral antiseptic agent and effectively assists in debriding the tongue and gums of dried secretions.6 Tongue cleaning The tongue traps millions of bacteria, playing a major role in providing the micro-organisms that form plaque, cause oral malodor and seed aspirated secretions. It too needs to be brushed or scraped at least twice daily, but accessing the posterior of the tongue during intubation is difficult. Commercial tongue scrapers remain uncommon in commercial oral care kits, so a toothbrush or edge of a tongue depressor may be used to scrape the tongue from posterior to anterior, after the gag point has been determined. The provider should be careful to suction the residue during the procedure so that it is not swallowed or aspirated. Providing comprehensive oral care may seem too basic to rank as critical care, but it is one of the most effective strategies available for prevention of VAP. When nurses are provided the training, time, tools and techniques to properly perform oral care, it can save lives - one patient at a time. 
Karen J. Ridley, RDH, MS received her certificate in Dental Hygiene from the Eastman Dental Center in Rochester, NY and her BS & MS in Dental Hygiene from Columbia University. She currently is on faculty at the University of Michigan School of Dentistry. Suzanne M. Pear , RN, PhD, CIC is a healthcare epidemiologist and Associate Director for Infection Prevention Practices with Kimberly-Clark Health Care.References 1. Fitch JA, Munro CL, Glass CA, Pellegrini JM. Oral care in the adult intensive care unit. Am J Crit Care 1999;8(5):314-318. 2. Jones H, Newton JT, Bower EJ. A survey of the oral care practices of intensive care nurses. Intensive Crit Care Nurs 2004;20(2):69-76. 3. Addems A, Epstein JB, Damji S, Spinelli J. The lack of efficacy of a foam brush in maintaining gingival health: a controlled study. Spec Care Dentist 1992;12(3):103-106. 4. Garcia R. A review of the possible role of oral and dental colonization on the occurrence of health care-associated pneumonia: underappreciated risk and a call for interventions. Am J Infect Control 2005;33(9):527-541. 5. O’Reilly M. Oral care of the critically ill: a review of the literature and guidelines for practice. Aust Crit Care 2003;16(3):101-110. 6. Senol G, Kirakli C, Halilcolar H. In vitro antibacterial activities of oral care products against ventilator-associated pneumonia pathogens. Am J Infect Control 2007;35(8):531-535. 7. Chan EY, Ruest A, Meade MO, Cook DJ. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis. BMJ 2007;334(7599):889- 8. Pineda LA, Saliba RG, El Solh AA. Effect of oral decontamination with chlorhexidine on the incidence of nosocomial pneumonia: a meta-analysis. Crit Care 2006;10(1):R35- 9. Raybould TP, Carpenter AD, Ferretti GA, Brown AT, Lillich TT, Henslee J. Emergence of gram-negative bacilli in the mouths of bone marrow transplant recipients using chlorhexidine mouthrinse. Oncol Nurs Forum 1994;21(4):691-696. 10. Ishikawa A, Yoneyama T, Hirota K, Miyake Y, Miyatake K. Professional oral health care reduces the number of oropharyngeal bacteria. J Dent Res 2008;87(6):594-598. 
|
