American Journal of Infection Control 43 (2015) 303-4
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Brief report
Oral hygiene protocols in intensive care units in a large Brazilian city Maria Elisa de Souza e Silva PhD a, *, Vera Lúcia Silva Resende PhD a, Mauro Henrique Nogueira Guimarães Abreu PhD b, André Vasconcelos Dayrell c, Débora de Andrade Valle c, Lia Silva de Castilho PhD b a
Department of Restorative Dentistry, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil Department of Social and Preventive Dentistry, School of Dentistry, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil c Undergraduate student of School of Dentistry of Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil b
Key Words: Ventilator-associated pneumonia Chlorhexidine Intensive care unit Oral hygiene Cetylpyridinium chloride
This study investigated oral hygiene protocols for patients in intensive care units (ICUs) in 25 of 30 hospitals in Belo Horizonte, Brazil, using a questionnaire. Although all hospital representatives said there was a protocol for the maintenance of patients’ oral hygiene, it was observed that there was no standardization. Only 2 hospitals had dentists on the ICU staff. Cetylpyridinium chloride was the most frequently used antiseptic, even in patients under mechanical ventilation. Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Oral health is fundamental to the well-being of hospitalized patients. A strict oral hygiene evaluation in these patients is essential; however, oral care is normally performed by a nursing staff that is insufficiently trained in oral health protocols.1 Oral health usually deteriorates after admission to the intensive care unit (ICU), and the build-up of bacterial plaque in these patients can lead to serious infections, such as pneumonia, mainly in patients receiving mechanical ventilation.2-5 The implementation of oral hygiene protocols in ICUs should be mandatory in the routine care of patients. Routine oral health care has the positive effect of preventing pneumonia, even among residents of long-stay institutions.5 However, oral hygiene procedures are rarely performed when a standardized protocol has not been established.6 The aim of the present study was to investigate whether there were oral hygiene protocols for hospital ICUs, what procedures were used to perform them, and what the hospital representatives’ or respondents’ opinion are about the importance of oral hygiene.
METHODS A descriptive study was conducted in Belo Horizonte Hospitals, Brazil, where the municipal health service is well structured, and * Address correspondence to Maria Elisa Souza e Silva, PhD, Adjunct Professor, Department of Restorative Dentistry, School of Dentistry, Universidade Federal de Minas Gerais, Avenida Presidente Antônio Carlos, 6627, Bairro São Francisco, Belo Horizonte, Minas Gerais, CEP 31270-000, Brazil. E-mail address: [email protected] (M.E.S. Silva). Conflicts of interest: None to report.
there is a very strict health vigilance department. After a query on the municipal home page, the hospitals with ICUs were noted, and telephone contact was initiated to assess willingness to participate in the study. There were 30 ICUs in 30 hospitals, but 5 of them declined to participate in the study. Questionnaires were personally administered to 25 health care professionals who were nominated by the 25 participant hospitals’ administration boards. At least 1 member of the research team went to each hospital to explain the objectives of the study and to ask the respondent to sign a formal consent form and complete the questionnaire. As a first question we asked whether there were any dental personnel among the ICU staff, and if the answer was yes, we asked about the responsibilities of those staff members. We also asked whether there was an oral hygiene protocol for ICUs for ventilated and nonventilated patients in that hospital, and if the answer was yes, we asked about toothbrushing frequency and use of mouthwash (kind or brand, source, and the person in charge of prescribing it: doctor, dentist, nurse, or family member). At the end of the questionnaire, we made the following statement: Having an oral hygiene protocol for ICU patients is important to the results of medical treatment. Respondents were asked to answer the statement using a Likert scale.
RESULTS The total bed count in the 25 investigated hospitals was 692 (ranging, 6-100), and each hospital had 1 ICU. Only 2 hospitals included a dentist on their multidisciplinary ICU team, and only 5
0196-6553/$36.00 - Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2014.11.027
304
M.E.S. e Silva et al. / American Journal of Infection Control 43 (2015) 303-4
Table 1 Description of some hospital characteristics and oral hygiene protocols in ICUs Variables
Mean SD (range)
ICU capacity (no. of beds) Dentist on the team Dental examination at admission* Oral hygiene protocol Means used for oral hygiene Antiseptic solution, gauze Only antiseptic solution Toothbrush, antiseptic solution, gauze Toothbrush, antiseptic solution Frequency of oral hygiene protocol (times/d) Antiseptic solution prescribed Cetylpyridinium chloride Chlorhexidine Chlorhexidine for patients under mechanical respiration and cetylpyridinium chloride for patients with spontaneous respiration Bicarbonate solution provided by hospital or other antiseptic provided by family Who prescribes the antiseptic solution? Nurse Doctor Doctor-nurse Dentist No prescription needed “I believe that an oral hygiene protocol is important to patient health.” Full agreement Partial agreement
27.7 19.5 (6-100)
Frequency (%) 692 2 5 25
(100) (8.0) (20.0) (100)
10 7 5 3
(40.0) (28.0) (20.0) (12.0)
2.84 0.79 (1-4)
11 (44.0) 8 (32.0) 5 (20.0)
1 (4.0)
12 8 1 1 3
(48.0) (32.0) (4.0) (4.0) (12.0)
23 (92.0) 2 (8.0)
ICU, intensive care unit. *In the hospitals surveyed, dental examinations aimed at evaluation for the presence of prostheses, oral lesions, and dental caries.
hospitals routinely requested a dentist to evaluate patients when they were admitted to the ICU (Table 1). All the hospital representatives and respondents said that there was an oral hygiene protocol for ICU patients. The most frequently used hygiene method involved the use of gauze soaked in an antiseptic solution, 1-4 times per day. In 3 hospitals (12%), only toothbrushing was used to apply antiseptic solution for oral hygiene; in 5 hospitals (20%), toothbrushes or gauze were used to apply antiseptic; and in 7 hospitals (28%), only an antiseptic solution was used, but the means of applying it were not reported. In 10 hospitals (40%), gauze was used to apply antiseptic solution (Table 1). One hospital (4%) routinely provided sodium bicarbonate; in another, mouthwash was used when purchased by patients’ families. Eight (32%) of 25 hospitals used chlorhexidine for all ICU patients; 16 (64%) used cetylpyridinium chloride for all their patients, and 5 out of these 16 hospitals (31%) used chlorhexidine for patients receiving mechanical respiration. The person in charge of prescribing antiseptic solutions was a nurse in 12 hospitals, a physician in 8 hospitals, a dentist in 1 hospital, and both a physician and nurse in 1 hospital. In 3 hospitals, a prescription was not necessary. Twenty-three hospital representatives (92%) responded “I strongly agree” that the use of an oral health protocol for patients in the ICU is important for the results of medical treatment; 1 responded “I agree,” and 1 responded “I disagree” (Table 1). DISCUSSION Not all of the surveyed hospitals had dentists or even dental hygienists as part of their multidisciplinary ICU staff. Dentists and
dental hygienists are the best-trained professionals to provide oral care, and they should work with other members of multidisciplinary teams to promote the health and well-being of hospitalized patients in ICUs. Insufficient information was reported as the main reason why oral hygiene was not routinely performed in ICUs.6 Hiring a dental professional to participate in the ICU care team would increase financial costs. All the respondents said that there was an oral hygiene protocol for their ICU patients. However, the rate of hospitals that did not use chlorhexidine for the oral hygiene of individuals receiving mechanical ventilation was a concern in this study (48%) because countries worldwide have been working to establish an oral hygiene protocol in ICUs, including the provision of chlorhexidine in ventilator associated Pneumonia bundles.7-9 Cetylpyridinium chloride solution was the most widely used antiseptic in the surveyed hospitals, and when patients were under mechanical ventilation, only 5 of these 16 used only chlorhexidine. Actually, cetylpyridinium chloride solution was used successfully in mechanically ventilated patients receiving oral care, but the rate of VAP decreased more with chlorhexidine gluconate 0.12%.8 In 1 ICU, saline solution was used for oral hygiene, even in patients receiving mechanical ventilation, which is not an ideal practice. Chlorhexidine is more expensive than saline solution; however, it is also more effective in preventing VAP, making it more affordable for ICUs.10 The use of other antiseptic solutions and methods for controlling dental biofilm should be considered in patients who are not receiving mechanical ventilation. CONCLUSIONS There was no standardization of the use of antiseptic solutions or of the manner in which the solutions were applied in ICU patients. Acknowledgment We thank Pró-reitoria de pesquisa-Universidade Federal de Minas Gerais. References 1. Edward K, Salamone K, Mills C, Mann R, Arunasalam K, McLean A, et al. Oral care for in-patients: current practice-future directions. Dental Nursing 2013;9:280-4. 2. Needleman I, Hyun-Ryu J, Brealey D, Sachdev M, Moskal-Fitzpatrick D, Bercades G, et al. The impact of hospitalization on dental plaque accumulation: an observational study. J Clin Periodontol 2012;39:1011-6. 3. Raghavendran K, Mylotte JM, Scannapieco FA. Nursing home-associated pneumonia, hospital-acquired pneumonia and ventilator associated pneumonia: the contribution of dental biofilms and periodontal inflammation. Periodontol 2000 2007;44:164-77. 4. Bergan EH, Tura BR, Lamas CC. Impact of improvement in preoperative oral health on nosocomial pneumonia in a group of cardiac surgery patients: a single arm prospective intervention study. Intensive Care Med 2014;40:23-31. 5. Sjögren P, Nilsson E, Forsell M, Johansson O, Hoogstraate JA. Systematic review of the preventive effect of oral hygiene on pneumonia and respiratory tract infection in elderly people in hospitals and nursing homes: effect estimates and methodological quality of randomized controlled trials. J Am Geriatr Soc 2008; 56:2124-30. 6. Pettit SL, McCann AL, Schineiderman ED, Farren EA, Campbell PR. Dimensions of oral care management in Texas hospitals. J Dent Hyg 2012;86:91-103. 7. Eom JS, Lee MS, Chum HK, Choi HJ, Jung SW, Kim YS, et al. The impact of a ventilator bundle on preventing ventilator-associated pneumonia: a multicenter study. Am J Infect Control 2014;42:34-7. 8. Hutchins K, Karras G, Erwin J, Sullivan KL. Ventilator-associated pneumonia and oral care: a successful quality improvement project. Am J Infect Control 2009;37:590-7. 9. Álvarez Lerma F, Sánchez García M, Lorente L, Gordo F, Añón JM, Álvarez J, et al. Guidelines for the prevention of ventilator-associated pneumonia and their implementation. The Spanish “Zero-VAP” bundle. Med Intensiva 2014;38:226-36. 10. Zhang TT, Tang SS, Fu LJ. The effectiveness of different concentrations of chlorhexidine for prevention of ventilator-associated pneumonia: a metaanalysis. J Clin Nurs 2014;23:1461-75.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Brief report
Oral hygiene protocols in intensive care units in a large Brazilian city Maria Elisa de Souza e Silva PhD a, *, Vera Lúcia Silva Resende PhD a, Mauro Henrique Nogueira Guimarães Abreu PhD b, André Vasconcelos Dayrell c, Débora de Andrade Valle c, Lia Silva de Castilho PhD b a
Department of Restorative Dentistry, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil Department of Social and Preventive Dentistry, School of Dentistry, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil c Undergraduate student of School of Dentistry of Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil b
Key Words: Ventilator-associated pneumonia Chlorhexidine Intensive care unit Oral hygiene Cetylpyridinium chloride
This study investigated oral hygiene protocols for patients in intensive care units (ICUs) in 25 of 30 hospitals in Belo Horizonte, Brazil, using a questionnaire. Although all hospital representatives said there was a protocol for the maintenance of patients’ oral hygiene, it was observed that there was no standardization. Only 2 hospitals had dentists on the ICU staff. Cetylpyridinium chloride was the most frequently used antiseptic, even in patients under mechanical ventilation. Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Oral health is fundamental to the well-being of hospitalized patients. A strict oral hygiene evaluation in these patients is essential; however, oral care is normally performed by a nursing staff that is insufficiently trained in oral health protocols.1 Oral health usually deteriorates after admission to the intensive care unit (ICU), and the build-up of bacterial plaque in these patients can lead to serious infections, such as pneumonia, mainly in patients receiving mechanical ventilation.2-5 The implementation of oral hygiene protocols in ICUs should be mandatory in the routine care of patients. Routine oral health care has the positive effect of preventing pneumonia, even among residents of long-stay institutions.5 However, oral hygiene procedures are rarely performed when a standardized protocol has not been established.6 The aim of the present study was to investigate whether there were oral hygiene protocols for hospital ICUs, what procedures were used to perform them, and what the hospital representatives’ or respondents’ opinion are about the importance of oral hygiene.
METHODS A descriptive study was conducted in Belo Horizonte Hospitals, Brazil, where the municipal health service is well structured, and * Address correspondence to Maria Elisa Souza e Silva, PhD, Adjunct Professor, Department of Restorative Dentistry, School of Dentistry, Universidade Federal de Minas Gerais, Avenida Presidente Antônio Carlos, 6627, Bairro São Francisco, Belo Horizonte, Minas Gerais, CEP 31270-000, Brazil. E-mail address: [email protected] (M.E.S. Silva). Conflicts of interest: None to report.
there is a very strict health vigilance department. After a query on the municipal home page, the hospitals with ICUs were noted, and telephone contact was initiated to assess willingness to participate in the study. There were 30 ICUs in 30 hospitals, but 5 of them declined to participate in the study. Questionnaires were personally administered to 25 health care professionals who were nominated by the 25 participant hospitals’ administration boards. At least 1 member of the research team went to each hospital to explain the objectives of the study and to ask the respondent to sign a formal consent form and complete the questionnaire. As a first question we asked whether there were any dental personnel among the ICU staff, and if the answer was yes, we asked about the responsibilities of those staff members. We also asked whether there was an oral hygiene protocol for ICUs for ventilated and nonventilated patients in that hospital, and if the answer was yes, we asked about toothbrushing frequency and use of mouthwash (kind or brand, source, and the person in charge of prescribing it: doctor, dentist, nurse, or family member). At the end of the questionnaire, we made the following statement: Having an oral hygiene protocol for ICU patients is important to the results of medical treatment. Respondents were asked to answer the statement using a Likert scale.
RESULTS The total bed count in the 25 investigated hospitals was 692 (ranging, 6-100), and each hospital had 1 ICU. Only 2 hospitals included a dentist on their multidisciplinary ICU team, and only 5
0196-6553/$36.00 - Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2014.11.027
304
M.E.S. e Silva et al. / American Journal of Infection Control 43 (2015) 303-4
Table 1 Description of some hospital characteristics and oral hygiene protocols in ICUs Variables
Mean SD (range)
ICU capacity (no. of beds) Dentist on the team Dental examination at admission* Oral hygiene protocol Means used for oral hygiene Antiseptic solution, gauze Only antiseptic solution Toothbrush, antiseptic solution, gauze Toothbrush, antiseptic solution Frequency of oral hygiene protocol (times/d) Antiseptic solution prescribed Cetylpyridinium chloride Chlorhexidine Chlorhexidine for patients under mechanical respiration and cetylpyridinium chloride for patients with spontaneous respiration Bicarbonate solution provided by hospital or other antiseptic provided by family Who prescribes the antiseptic solution? Nurse Doctor Doctor-nurse Dentist No prescription needed “I believe that an oral hygiene protocol is important to patient health.” Full agreement Partial agreement
27.7 19.5 (6-100)
Frequency (%) 692 2 5 25
(100) (8.0) (20.0) (100)
10 7 5 3
(40.0) (28.0) (20.0) (12.0)
2.84 0.79 (1-4)
11 (44.0) 8 (32.0) 5 (20.0)
1 (4.0)
12 8 1 1 3
(48.0) (32.0) (4.0) (4.0) (12.0)
23 (92.0) 2 (8.0)
ICU, intensive care unit. *In the hospitals surveyed, dental examinations aimed at evaluation for the presence of prostheses, oral lesions, and dental caries.
hospitals routinely requested a dentist to evaluate patients when they were admitted to the ICU (Table 1). All the hospital representatives and respondents said that there was an oral hygiene protocol for ICU patients. The most frequently used hygiene method involved the use of gauze soaked in an antiseptic solution, 1-4 times per day. In 3 hospitals (12%), only toothbrushing was used to apply antiseptic solution for oral hygiene; in 5 hospitals (20%), toothbrushes or gauze were used to apply antiseptic; and in 7 hospitals (28%), only an antiseptic solution was used, but the means of applying it were not reported. In 10 hospitals (40%), gauze was used to apply antiseptic solution (Table 1). One hospital (4%) routinely provided sodium bicarbonate; in another, mouthwash was used when purchased by patients’ families. Eight (32%) of 25 hospitals used chlorhexidine for all ICU patients; 16 (64%) used cetylpyridinium chloride for all their patients, and 5 out of these 16 hospitals (31%) used chlorhexidine for patients receiving mechanical respiration. The person in charge of prescribing antiseptic solutions was a nurse in 12 hospitals, a physician in 8 hospitals, a dentist in 1 hospital, and both a physician and nurse in 1 hospital. In 3 hospitals, a prescription was not necessary. Twenty-three hospital representatives (92%) responded “I strongly agree” that the use of an oral health protocol for patients in the ICU is important for the results of medical treatment; 1 responded “I agree,” and 1 responded “I disagree” (Table 1). DISCUSSION Not all of the surveyed hospitals had dentists or even dental hygienists as part of their multidisciplinary ICU staff. Dentists and
dental hygienists are the best-trained professionals to provide oral care, and they should work with other members of multidisciplinary teams to promote the health and well-being of hospitalized patients in ICUs. Insufficient information was reported as the main reason why oral hygiene was not routinely performed in ICUs.6 Hiring a dental professional to participate in the ICU care team would increase financial costs. All the respondents said that there was an oral hygiene protocol for their ICU patients. However, the rate of hospitals that did not use chlorhexidine for the oral hygiene of individuals receiving mechanical ventilation was a concern in this study (48%) because countries worldwide have been working to establish an oral hygiene protocol in ICUs, including the provision of chlorhexidine in ventilator associated Pneumonia bundles.7-9 Cetylpyridinium chloride solution was the most widely used antiseptic in the surveyed hospitals, and when patients were under mechanical ventilation, only 5 of these 16 used only chlorhexidine. Actually, cetylpyridinium chloride solution was used successfully in mechanically ventilated patients receiving oral care, but the rate of VAP decreased more with chlorhexidine gluconate 0.12%.8 In 1 ICU, saline solution was used for oral hygiene, even in patients receiving mechanical ventilation, which is not an ideal practice. Chlorhexidine is more expensive than saline solution; however, it is also more effective in preventing VAP, making it more affordable for ICUs.10 The use of other antiseptic solutions and methods for controlling dental biofilm should be considered in patients who are not receiving mechanical ventilation. CONCLUSIONS There was no standardization of the use of antiseptic solutions or of the manner in which the solutions were applied in ICU patients. Acknowledgment We thank Pró-reitoria de pesquisa-Universidade Federal de Minas Gerais. References 1. Edward K, Salamone K, Mills C, Mann R, Arunasalam K, McLean A, et al. Oral care for in-patients: current practice-future directions. Dental Nursing 2013;9:280-4. 2. Needleman I, Hyun-Ryu J, Brealey D, Sachdev M, Moskal-Fitzpatrick D, Bercades G, et al. The impact of hospitalization on dental plaque accumulation: an observational study. J Clin Periodontol 2012;39:1011-6. 3. Raghavendran K, Mylotte JM, Scannapieco FA. Nursing home-associated pneumonia, hospital-acquired pneumonia and ventilator associated pneumonia: the contribution of dental biofilms and periodontal inflammation. Periodontol 2000 2007;44:164-77. 4. Bergan EH, Tura BR, Lamas CC. Impact of improvement in preoperative oral health on nosocomial pneumonia in a group of cardiac surgery patients: a single arm prospective intervention study. Intensive Care Med 2014;40:23-31. 5. Sjögren P, Nilsson E, Forsell M, Johansson O, Hoogstraate JA. Systematic review of the preventive effect of oral hygiene on pneumonia and respiratory tract infection in elderly people in hospitals and nursing homes: effect estimates and methodological quality of randomized controlled trials. J Am Geriatr Soc 2008; 56:2124-30. 6. Pettit SL, McCann AL, Schineiderman ED, Farren EA, Campbell PR. Dimensions of oral care management in Texas hospitals. J Dent Hyg 2012;86:91-103. 7. Eom JS, Lee MS, Chum HK, Choi HJ, Jung SW, Kim YS, et al. The impact of a ventilator bundle on preventing ventilator-associated pneumonia: a multicenter study. Am J Infect Control 2014;42:34-7. 8. Hutchins K, Karras G, Erwin J, Sullivan KL. Ventilator-associated pneumonia and oral care: a successful quality improvement project. Am J Infect Control 2009;37:590-7. 9. Álvarez Lerma F, Sánchez García M, Lorente L, Gordo F, Añón JM, Álvarez J, et al. Guidelines for the prevention of ventilator-associated pneumonia and their implementation. The Spanish “Zero-VAP” bundle. Med Intensiva 2014;38:226-36. 10. Zhang TT, Tang SS, Fu LJ. The effectiveness of different concentrations of chlorhexidine for prevention of ventilator-associated pneumonia: a metaanalysis. J Clin Nurs 2014;23:1461-75.
