Oral care practices for patients in Intensive Care Units: A pilot survey (2024)

Abstract

Keywords: Dental hygiene, education, hospital dental services, Intensive Care Unit, nursing services, oral care, oral health, ventilator-associated pneumonia

Introduction

Hospitalized patients, especially those in Intensive Care Units (ICUs), require specialized care. Their critical health conditions make them more dependent on a multidisciplinary team able to provide ethical, humane, and clinical help, especially in their daily activities. Most of these patients are not able to perform the simplest activities, including their own oral hygiene. Thus, providing oral care to these patients is very important.[1,2]

Oral hygiene is necessary for patients in ICUs because it helps to maintain the health of their stomatognathic systems. Without proper assistance, the health conditions of critical patients in the ICU may be aggravated. In addition, oral hygiene is often precarious in ICU patients. Finally, changes in salivary flow caused by medications that worsen and unbalance the oral environment may increase biofilm formation.[2,3,4]

Previous reports have suggested that professionals working in Brazilian hospitals give little credibility to dental activities such as oral hygiene, and do not usually recognize the close association between oral hygiene and prevention of systemic diseases. Health care professionals must be made aware that oral hygiene may improve the health conditions of hospitalized patients.[3]

Dentistry practice in hospitals aims to prevent and eliminate potential infection sources, including inflammation and painful symptoms caused by oral problems that may directly affect systemic conditions of critically ill patients and jeopardize their recovery.[5,6]

Most dentistry performed in hospitals focuses on curative and rehabilitative treatments. However, education and prevention are equally important, and require interdisciplinary approaches.[7]

Dentists working in ICUs play an important role in patient oral health. They assess the accumulation of biofilm, tongue coating, dental caries, halitosis, oral lesions, partial or full prosthetics, periodontal disease, and residual fungal diseases within the oral cavity.[3,8,9]

Gram-positive bacteria often constitute the oral microflora of healthy individuals. However, the balance of oral microflora of patients hospitalized in ICUs for more than 48 h tends to change. These changes lead to a prevalence of Gram-negative bacteria such as Staphylococcus aureus, Streptococcus pneumoniae, Acinetobacter baumanii, Haemophilus influenzae, and Pseudomonas aeruginosa. These bacteria have all been associated with nosocomial pneumonia.[8,9]

Studies have correlated biofilm on the tongue with increased levels of Gram-negative bacteria. Biofilm on tooth surfaces, coated tongues, and periodontal disease tend to aggravate patient clinical conditions because they offer an optimal environment for growth of Gram-negative bacteria. This growth results in more virulent oral microflora. Therefore, dentists and other professionals involved in caring for critically ill patients should be aware of the need for effective elimination of these factors and prevention of bacterial development in the mouth.[3,5,8,9]

Nursing technicians are mostly responsible for performing oral hygiene in critically ill patients in ICUs. These professionals are supervised in the promotional activities of oral health for nurses and medical staff. However, the daily activities of care and work require a lot of attention to intensive care patients.[1,6,10]

The current study evaluated measures used by healthcare professionals to promote oral health in critically ill patients in ICUs. It also assessed the major difficulties encountered while carrying out preventive protocols for oral health promotion in ICUs of hospitals in Brasilia, Brazil.

Study Population and Methods

Results

The study sample consisted of 71 health professionals working in the ICUs of two private hospitals in Brasilia, Brazil. Among these professionals, the majority (80.3%) were nurse technicians and nurses (41; 57.8% and 16; 22.5%, respectively). Doctors, physiotherapists, and speech therapists were also included in the total sample. The professionals’ characteristics are shown in Table 1. Most professionals reported working in the ICU between 1–3 (45.1%) and 4–6 years (24%), with a typical 12-h workday (70.4%). There was a wide distribution in their qualifications.

Table 2 summarizes the professionals’ knowledge about coated tongue, biofilms, and nosocomial pneumonia. A significant proportion reported knowing about coated tongue (87.3%) and nosocomial pneumonia (66.2%) (P < 0.05). However, a similar proportion of professionals had no knowledge about biofilms (P > 0.05).

Most professionals (97.2%) reported performing activities to promote patient health, 83.1% cleaned the oral cavities of patients in the ICU, and 83.7% cleaned the oral cavities of patients with orotracheal intubation (P < 0.05). Approximately 46.5% of professionals reported practicing oral care at least twice daily, and 33.8% reported practicing oral care three times daily [Table 3].

The methods for oral care varied [Table 3], and more than one method was often used. Spatulas, gauze, and toothbrushes were the primary materials used by the majority (49.3%) of professionals (P < 0.017). Some (28.2%) used only toothbrushes. Among 71 professionals, 49.3% reported using a 0.12% chlorhexidine mouthwash (P < 0.017), whereas 16.9% used only toothpaste, and 11.3% used both chlorhexidine and toothpaste. Only 1.4% of the professionals did not use a chemical for biofilm control.

The t-statistic was significant at the 0.05 critical alpha level. However, it was used Bonferroni's theorem to adjust the critical alpha level (0.05) because the plan involved multiple tests of the same type (0.05/2) – P < 0.025 and (0.05/3) – P < 0.017.

Most professionals reported having a positive attitude toward providing oral care for ICU patients [Table 4], with 83.1% agreeing that oral care is a high-priority procedure for mechanically ventilated patients (P < 0.05). Approximately 80.3% agreed that they had adequate time to perform oral care procedures (P < 0.05), and 76.1% confirmed that they used an aspiration vacuum to perform oral hygiene procedures on ICU patients (P < 0.05). However, 56.4% of the professionals felt that the oral cavity was a difficult body area to clean (P < 0.05).

Discussion

This study describes the knowledge of health professionals working in the ICUs of two private hospitals in Brasilia, Brazil. The results indicate that the frequency and methods for providing oral care differed among nurses and nursing technicians. Although research has been conducted in ICUs of these hospitals, this study provides important information regarding oral hygiene practices in ICUs and identified difficulties in providing this care to hospitalized patients.

The results showed that over 80% of the professionals in this study were nurses and nursing technicians who performed tasks associated with oral health in patients in ICUs [Table 1]. Other studies have also reported that daily oral hygiene, mainly the removal of plaque and tongue coatings, is important for health promotion in patients in ICUs patients; this care is usually performed by qualified nursing staff who have been trained in specific oral hygiene methods and protocols.[14,15,16,17]

This study [Table 2] observed that 87.3% and 66.2% of the professionals had knowledge regarding tongue coating and nosocomial pneumonia, respectively (P = 0.00 and P < 0.05, respectively). These results are similar to those reported by Barnes[18] in which the majority of health professionals were aware of the clinical conditions most frequently present in the oral cavity of ICU patients, including tongue coating and systemic problems, especially nosocomial pneumonia.

The difficulty of maintaining oral hygiene in intubated patients was a major problem reported by more than 83% of the respondents (P = 0.00) [Table 3]. Oral health is a constant concern in ICUs, especially in intubated patients;[10] inadequate hygiene can contribute to the accumulation of microbial reservoirs associated with biofilm and tongue coatings, which may lead to systemic harm in these patients.

Oral health care in the ICU is a routine procedure in hospitals [Table 3], representing 83.1% of the sample (P = 0.00); however, in a study by Berry et al.,[19] there is no standardization for the frequency, technical preparation, clinical management, time for execution, motivation, and professional capacities, based on information provided by the majority of the study participants.

Most of the professionals in this study performed oral hygiene at least twice daily [Table 3], a significant difference compared to other routines (P = 0.025) [Table 3]. This frequency of oral hygiene in the ICU was also reported by Sona et al.,[4] Soh et al.,[13] and Munro et al.,[20] with the aim of reducing biofilm formation and tongue coating, and subsequently reducing the number of hospital infections.

Mechanical cleaning is an essential activity in oral health care in ICUs,[2,13,19] including the use of toothbrushes, gauze, and wooden spatulas (P = 0.017); this method was most commonly used by the professionals in this study [Table 3], along with chemical cleaning with 0.12% chlorhexidine (83.7% of professionals).

Combined chemical (0.12% chlorhexidine) and mechanical cleaning should be performed on all hospitalized patients in the ICU, as it has been shown to decrease the incidence of opportunistic infections such as nosocomial pneumonia.[7,20,21,22] This practice is primarily indicated for intubated patients because the tube and feeding ducts are niches for the accumulation of Gram-negative bacteria.[12,18,19] The findings of the current study are similar to those of previous reports.[3,4,7,8,10,15,20,22]

Knowledge about the importance of maintaining oral health for prevention of respiratory diseases in the hospital environment, particularly the ICU, was also observed in this study [Table 4], similar to that observed in other studies.[6,8,9]

These hygienic practices should be standard treatments performed by all professionals working in ICUs to provide adequate care to hospitalized patients.[15,16,18,20]

The majority of health professionals working in the ICU in the current study (80.3%) associated oral hygiene activities with other care practices for critical patients [Table 4] and reported having adequate time to execute these tasks. Although they reported some difficulties in performing proper oral hygiene (P = 0.03), most performed them with the help of vacuum aspiration (P < 0.05), a finding similar to those reported in previous studies.[2,11,12,19,22]

It is important for healthcare professionals to seek training on measures and protocols that promote the oral health of patients in ICUs.[5,18] The results of the current study reveal differences in practices and knowledge among the healthcare professionals evaluated in this study, indicating the need for additional educational and preparatory activities to improve oral health services performed in the ICUs evaluated in this study.

Conclusion

The results of this study suggest that is necessary to educate ICU professionals about the association between dental plaque and systemic condition of patients, improve training of ICU professionals, and standardize oral care protocols to promote oral health of patients in ICUs.

Acknowledgments

Questionnaire applied to health professionals from hospitals 1 and 2

References