Routine oral care interventions can reduce bacteria within the oral cavity and on the mucosal membranes and dentition, reducing the risk that bacteria may be mixed with food, liquids, or saliva and misdirected into the airway during the swallow. Surveys of patients also revealed that oral care routines and maintaining a healthier oral environment was related to a greater sense of self-worth (Niesten et al., 2013). Regular oral hygiene may improve patient comfort and may also help prevent xerostomia, which may be related to mouth-breathing, an open-mouth posture, or as a side effect of various medications (Choi et al., 2021).

Who is at risk?

Poor oral care has been identified as predictor of aspiration pneumonia in patients with dysphagia. Additionally, dependence on others for oral care provision places a patient at higher risk for aspiration pneumonia (Langmore et al., 1998). Older patients, patients with a decreased level of consciousness, and patients with decreased mobility or who are laying supine throughout the day are also at an increased risk (Wainer, 2020).

It is important that all patients be screened for oral health status to assist in identifying patients who are at a higher risk of developing hospital-acquired aspiration pneumonia. Research has determined that screening protocols such as the Oral Health Assessment Tool are both valid and reliable when used by nursing and allied health clinicians (Chalmers et al., 2005). An initial screening can also provide baseline information for comparison as subsequent oral care treatments and assessments are performed.  

Sample components of an oral health screen include assessing:

  • Quality and quantity of oral secretions.
  • Condition of oral mucosa
  • Appearance of the lips.
  • Condition of dentition: Presence of dentures (and fit); Broken, missing, or decayed teeth.
  • Appearance and mobility of the tongue.
  • Signs of lesions, ulcers, or redness.
  • Signs of infection or injury.
  • Presence of any residue
  • Level of dependence for performing care.

Endotracheal Intubation

Patients who receive mechanical ventilation via endotracheal intubation experience a reduction in their ability to resist the colonization of harmful microorganisms in the oral cavity. This may be due to prolonged mouth opening, which reduces the flow of saliva, and placement of the endotracheal tube. The obstruction caused by the endotracheal tube itself hinders accessibility for oral care, allowing for the buildup of a resistant oral biofilm. The endotracheal tube may then serve as a vehicle for the transportation of harmful bacteria from the oral cavity to the lungs. Even with the inflated cuff, microaspirations may occur and contribute to the development of ventilator-associated pneumonia (VAP) (Wainer, 2020). Research has shown that providing effective oral care may result in a lower incidence of VAP, reduced requirement for mechanical ventilation, shorter ICU stays, and lower mortality (de Lacerda Vidal et al., 2017).

Tracheostomy

The timing of the decision to tracheostomize following endotracheal intubation may also impact a patient’s oral health. A tracheostomy allows better access to the oral cavity for improved oral hygiene, requires less sedation, and allows for the possibility of oral intake, which may improve the oral environment. Additionally, deflating the tracheostomy tube cuff and placing a Passy-Muir® Valve restores airflow through the nose and mouth and improves management and expectoration of saliva and secretions, which may assist in the maintenance of a healthy oral environment. 

NPO

Patients with an endotracheal tube are nil per os (NPO), meaning nothing by mouth, as are many patients with tracheostomy prior to a swallowing assessment. Patients who are NPO typically receive, either temporarily or permanently, nutrition via nasogastric or gastrostomy tube. These patients are at an even higher risk of aspiration of oral pathogens than patients who are fed orally. This may be due to a reported decreased amount of attention paid to the oral cavities of patients who are not receiving an oral diet (Yatera & Mukae, 2020). These patients can and should be receiving regular oral care. A cleaner oral environment would not only decrease the risk of aspiration of respiratory pathogens and improve the oral environment but may also allow the patient to better participate in dysphagia treatment. The Frazier Free Water Protocol and the Ice Chip Protocol both require thorough oral care be provided prior to initiation (Gillman et al., 2017; Pisegna & Langmore, 2018). 

So, what’s the problem?

Though the research to support the benefits of oral care exists across multiple studies, diagnoses, and medical settings, oral hygiene is often not provided unless there is a standardized protocol in place. Research has investigated a knowledge gap that exists between understanding the importance of oral care and actually performing oral care tasks for patients. 

Pettit et al. (2012) surveyed a random sample of registered nurses using a mailed questionnaire that assessed oral care knowledge, practices, perceptions of importance, and barriers to providing oral care. While a large majority of respondents, reported they believed oral care was important (95%) and felt responsible for providing oral care (79%), over half (52%) admitted oral care was addressed only minimally in their nursing education and training. Reported barriers to performing oral care included, low priority, lack of time, lack of resources, and no employer mandate.

Common barriers to oral care have been reported as:

  • Lack of staff education and training
  • Limited availability of or access to supplies.
  • Unknown roles and responsibilities.
  • Lack of protocol.
  • Time constraints.
  • Documentation issues.
  • Lower priority of patient care tasks.
  • Staffing issues.

While much of the research on and perceived responsibility of oral hygiene focuses on nurses and nursing staff, it is important to understand that all members of the interdisciplinary team play an important role in the development and routine practice of better oral care protocols. Having an interdisciplinary approach will further improve compliance and lead to improved patient comfort and a decreased risk of aspiration of oral bacteria, a potential contributor to the development of acquired pneumonia (Yatera & Mukae, 2020).

Developing a protocol

Education and training are a great place to start with implementing a successful oral care protocol. At all levels of care and in all healthcare settings, clinicians, patients, and patients’ caregivers should be educated on the importance of oral care, the risks of poor oral hygiene, and how and when to perform oral care. 

Sample staff training interventions include:

  • Providing in-service training
  • Demonstration videos.
  • Hands-on demonstration.
  • Skills lab.
  • Competency checklist.
  • Defining roles and responsibilities.
  • Benefits training.
  • Assessment and routine documentation.

Wennerholm et al. (2021) detailed a facility’s development of a multidisciplinary Oral Care Task Force to improve the provision of oral care. This facility screened patients and placed them into one of four categories based on needs. They developed oral care kits based on those categories of patient need and made them easily available to staff or patients if patients were deemed independent. The task force focused on e-learning and hands-on demonstrations for performing oral care with a standardized protocol and developed a documentation template in the electronic medical record to aid in ease and compliance of documentation. They determined that while this project was challenging, it was feasible and successful to lower the rate of hospital-acquired aspiration pneumonia (Wennerholm et al., 2021).

Another study found that by increasing the supply and availability of oral care tools and creating a standardized placement of those tools in the patients’ rooms, oral hygiene for patients receiving mechanical ventilation improved significantly (Diaz et al., 2017). They reported that having a standardized oral hygiene placement protocol in the patient’s room significantly improved staff compliance and patient outcomes.

Oral care kits should be kept at the patient bedside for ease of access and use. Even patients who are deemed independent in performing oral care or have available caregivers may benefit from ease of access to supplies, education, and encouragement to perform oral care. 

Sample oral care kit supplies include:

  • Toothbrush (suction toothbrush).
  • Toothpaste (consider non-foaming).
  • Oral swabs.
  • Distilled water.
  • Oral antiseptic.
  • Clean cloth, gauze, or wipe.
  • Basin.
  • Lip balm (mouth moisturizer).
  • Denture adhesive, if needed.

Patients should receive or perform oral care at least 2 – 3 times daily and prior to any oral intake. Using it prior to oral intake decreases the presence of oral bacteria that may be misdirected toward the airway during the swallow. If a patient wears dentures, they should also be cleaned, in addition to the performance of regular oral hygiene. It is important that the dentures be completely removed for proper cleaning of the gums and palate. A simply written step-by-step protocol for patient at each level of care has been shown to improve patient outcomes, increase provision of oral care services, and reduce healthcare costs (Quinn & Baker, 2015). 

References

Chalmers, J. M., King, P. L., Spencer, A. J., Wright, F. A., & Carter, K. D. (2005). The oral health assessment tool – validity and reliability. Australian Dental Journal, 50(3), 191–199. https://doi.org/10.1111/j.1834-7819.2005.tb00360.x

Choi, E.S., Noh, H.J., Chung, W.G., & Mun, S.J. (2021). Development of a competency for professional oral hygiene care of endotracheally-intubated patients in the intensive care unit: development and validity evidence. BMC Health Services Research, 21https://doi.org/10.1186/s12913-021-06755-z

Diaz, T.L., Zanone, S.J., Charmo-Smith, C., Kamoun, H., & Barrais, A.I. (2017). Oral care in ventilated intensive care unit patients: observing nursing behavior through standardization of oral hygiene tool placement. American Journal of Infection Control, 45(5). 559-561. https://doi.org/10.1016/j.ajic.2016.12.008

de Lacerda Vidal, C.F., de Lacerda Vidal, A.K., de Moura Monteiro, J.G., Cavalcanti, A., da Costa, A.P., Oliveira, M., Godoy, M., Coutinho, M., Sobral, P.D., Vilela, C.A., Gomes, B., Leandro, M.A., Montarroyos, U., de Alencar Ximenes, R., & Lacerda, H.R. (2017). Impact of oral hygiene involving toothbrushing versus chlorhexidine in the prevention of ventilator-associated pneumonia: a randomized study. BMC Infectious Diseases, 17(112). https://doi.org/10.1186/s12879-017-2188-0

Gillman, A., Winkler, R. & Taylor, N.F. (2017). Implementing the Free Water Protocol does not result in aspiration pneumonia in carefully selected patients with dysphagia: a systematic review. Dysphagia, 32, 345–361. https://doi.org/10.1007/s00455-016-9761-3

Langmore, S. E., Terpenning, M. S., Schork, A., Chen, Y., Murray, J. T., Lopatin, D., & Loesche, W. J. (1998). Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia, 13(2), 69–81. https://doi.org/10.1007/PL00009559

Niesten, D., van Mourik, K. & van der Sanden, W. (2013). The impact of frailty on oral care behavior of older people: a qualitative study. BMC Oral Health (13)61. https://doi.org/10.1186/1472-6831-13-61  

Pettit, S.L., McCann, A.L., Schneiderman, E.D., Farren, E.A., & Campbell, P.R. (2012). Dimensions of oral care management in Texas hospitals. Journal of Dental Hygiene, 86(2), 91-103. https://pubmed.ncbi.nlm.nih.gov/22584446/

Pisegna, J.M. & Langmore, S.E. (2018). The Ice Chip Protocol: a description of the protocol and case reports. SIG 13 Swallowing and Swallowing Disorders, 3(13), 28-46. https://doi.org/10.1044/persp3.SIG13.28

Quinn, B., & Baker, D. (2015). Comprehensive oral care helps prevent hospital-acquired nonventilator pneumonia: a nurse-led prevention initiative proved that oral care is far more than just a comfort measure. American Nurse Today, 10(3), 18-23. https://link.gale.com/apps/doc/A411615948/HRCA?u=tel_oweb&sid=googleScholar&xid=191a63be

Wainer, C. (2020). The importance of oral hygiene for patients on mechanical ventilation. British Journal of Nursing, 29(15). https://doi.org/10.12968/bjon.2020.29.15.862

Wennerholm, L., Perez, N.R., Abt, S., Fon, K., & Elsabrout, K. (2021). Development of an oral care multidisciplinary initiative in an acute care community hospital: framework, timeline, and outcomes. American Journal of Speech-Language Pathology, 30, 517-531. https://doi.org/10.1044/2020_AJSLP-20-00159

Yatera, K., & Mukae, H. (2020). Clinical significance of aspiration pneumonia in all the pneumonia therapy: the impact of aspiration pneumonia on the therapeutic approach for all pneumonia. In Teramoto, S. & Komiya, K. (Eds.), Respiratory Disease Series: Diagnostic Tools and Disease Managements: Aspiration Pneumonia— The Current Clinical Giant for Respiratory Physicians (pp. 15–26). Springer. https://doi.org/10.1007/978-981-15-4506-1_2

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Tiffany graduated with a Master’s in Speech-Language Pathology from the UTHSC in 2012. She has been a medical SLP in various settings from acute care to home health, treating both the adult and medically complex pediatric populations. She has developed patient care pathways to guide assessment and treatment selection for patients in home health, at both the state and national level. She is a volunteer for Remote Area Medical (RAM), assisting with medical services. She also participates in the development of multimedia education related to healthcare and clinical practice. She is currently a Clinical Specialist with Passy-Muir, Inc.

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