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Oral hygiene care in the pediatric intensive care unit: practice recommendations.

Oral hygiene in children is essential for the development of strong, healthy teeth and to minimize the risk of infection (Thomson, Ayers, & Broughton, 2003). In the critical care setting, poor oral hygiene has been associated with increased dental plaque accumulation, bacterial colonization of the oropharynx, and higher nosocomial infection rates, particularly ventilator-associated pneumonia (VAP) (Fourrier, Duvivier, Boutigny, Roussel-Delvallez, & Chopin, 1998; Franklin, Senior, James, & Roberts, 2000; Grap & Munro, 2004). Yet, research suggests that some nurses perceive oral hygiene care to be a low priority (McNeill, 2000; O'Reilly, 2003), and they may lack the necessary knowledge of oral health assessment and hygiene practices (Adams, 1996; Fitch, Munro, Glass, & Pellegrini, 1999).

Developmental dental physiology provides an essential background for justifying age-appropriate interventions and the importance of good oral hygiene for children. Tooth development begins in utero and continues until after the teeth erupt (Durso, 2005). The first deciduous teeth, also known as milk teeth, appear at approximately 6 months of age. The eruption of permanent teeth causes deciduous teeth to loosen and fall out between the ages of 6 and 12 years. The final permanent teeth, the third molars or wisdom teeth, generally erupt between 17 and 25 years of age (Marieb, 1998). Teeth act as a host for dental plaque, which in turn, acts as a host for harmful pathogens. When teeth first erupt, they take up to two years to develop surface minerals that provide protection against tooth decay. Newly erupted teeth are therefore more vulnerable to tooth decay when compared with teeth that have been erupted for more than a couple of years (Wong et al., 1999).

Saliva plays a major role in cleansing the mouth by keeping mucous membranes moist, regulating the pH of the mouth, and digesting food. A biofilm or pellicle is formed from saliva, and this acts as a protective layer for teeth (O'Reilly, 2003). Saliva also contains natural antimicrobial proteins that protect the oral cavity from harmful pathogens (Brennan et al., 2004). In addition to saliva, oral health is maintained by regularly eating and drinking, as well as daily mechanical and pharmacological maintenance of the mouth (O'Reilly, 2003), for example, brushing teeth with fluoride toothpaste and flossing.

Dental plaque results from the colonization and growth of a variety of microorganisms on the surfaces of teeth, soft tissues, and dental prostheses. Seventy (70%) to 80% of the solid material in plaque is made up of bacteria and 1 [mm.sup.3] contains more than 108 bacteria with more than 300 varying aerobic and anaerobic species of bacteria (Fourrier et al., 1998). Poor oral hygiene and an accumulation of dental plaque lead to dental caries. This can be painful, costly, and when not treated, will progress to serious tooth damage. Poor oral hygiene will also result in gingivitis (gum disease), which occurs within less than 10 days if dental plaque is not removed. It is characterized by inflamed and bleeding gums that detach from the teeth and result in pocketing between the gums and the teeth (Franklin et al., 2000). Gingivitis is the first stage of periodontal disease, which if left untreated, can progress to periodontitis (Durso, 2005; Marieb, 1998).

Within 48 hours of hospital admission, the oropharyngeal flora of critically unwell patients undergoes a change from predominantly gram positive organisms to predominantly gram negative organisms, creating a more virulent flora (Munro & Grap, 2004). This bacterial flora may then migrate to the lungs and result in a hospital-acquired pneumonia. The risk is more pronounced when access to the respiratory tract is impaired due to intubation. Millikan et al. (1988) reported an 11% total mortality rate from nosocomial infections in PICU children. VAP has been documented to be the second most common cause of nosocomial infection in PICU children, with bloodstream infections being the leading cause. The most common pathogens found to cause VAP in PICU children are pseudomonas aeruginosa (21.8%), Staphylococcus aureus (16.9%), and Hemophilus influenzae (10.2%) (Richards, Edwards, Culver, Gaynes, & the National Nosocomial Infection Surveillance System, 1999). In the PICU, VAP has also been associated with congenital syndromes, re-intubation, transport out of the PICU, and bloodstream and central venous line infections (Elward, Warren, & Fraser, 2002).


An endotracheal tube (ETT) provides a pathway for bacteria into intubated children's lungs (Franklin et al., 2000; Grap & Munro, 2004). Intubated children are at greater risk of developing pneumonia because of their poor or absent cough and gag reflex, as well as their immobility. Intubated children are nil per os (NPO) and likely to have a nasal or oro-gastric tube in situ that passes through the oral cavity, causing the child's mouth to be continuously open, which in turn may contribute to xerostomia (Munro & Grap, 2004). Furthermore, PICU children are often on medications and infusions (such as inotropes, diuretics, anticonvulsants, anticholinergics, and sedatives) that may lead to or exacerbate xerostomia, a decrease in salivary production leading to a dry mouth (McNeill, 2000). The risk of xerostomia is further exacerbated by stimulation of the sympathetic nervous system and dehydration (McNeill, 2000; Munro & Grap, 2004).

Compared with adult ICU patients, PICU children have a number of differences that may increase their risk of developing VAR These include an uncuffed ETT, a nasal ETT, open circuit suctioning, saline lavage during suctioning, and developing dentition (Institute for Healthcare Improvements [IHI], 2005).

In a large New Zealand PICU, informal discussions identified significant diversity in the oral care provided by nurses. A goal was identified--"To improve standards of oral care for children in the PICU." To accomplish this goal, an evidence-based practice process informed by the 1998 Iowa Model was implemented (see Figure 1) (Titler et al., 2001).

Triggers Contributing To the Problem

The first step in the Iowa Model is to identify "triggers" to the problem. A survey of nurses was conducted to establish baseline knowledge of oral hygiene and current oral hygiene practices in the PICU. Following ethical Institution Review Board (IRB) approval, all PICU nurses were invited to anonymously complete the 14-item questionnaire developed by the investigator. Depending on the type of question, nurses answered each question using a Likert Scale, circling yes or no, or ticking boxes that indicated their practice in relation to the question. After one month, 47 of the 65 nurses had returned the questionnaire (response rate of 72%). The results confirmed that while most nurses considered oral hygiene to be important, there was a need for staff education and a clinical guideline (see Table 1). The problem-based triggers the survey identified included a) absence of a clinical protocol for oral hygiene, b) multiple oral hygiene practices including inadequate oral hygiene cares, c) the lack of consistent oral hygiene care, d) poor knowledge of effective oral hygiene care, and e) lack of appropriate oral hygiene equipment.

Literature Review

Having identified the problem--poor oral hygiene care in the PICU--a literature search was undertaken to gather relevant literature and research studies. The Cochrane Library, Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health (CINAHL), and Medline were searched (restricted to 1990-2006, English language, and human research), including the related links option and journal cross referencing for papers not previously identified. The search produced a number of articles on oral hygiene and ventilator-associated pneumonia in adult intensive care units. However, very little research was found specific to oral hygiene in the pediatric critical care setting. The Iowa Model encourages the use of case reports, expert opinion, and theories to inform practice when research findings are not available (Titler et al., 2001), allowing protocols to be developed based on "best available evidence." Fourteen articles were identified as relevant to pediatric oral care in the critical care setting and were subsequently appraised (see Table 2). They included two systematic reviews, two randomized controlled trials (with adequate sample size), four non-randomized trials (or randomized with small sample sizes), one comparative trial, and five expert opinions. Only four of the 14 articles were specific to the pediatric population.

Using definitions developed by Stetler and colleagues (1998), levels were assigned that rated the quality or strength of evidence of the 14 studies. Levels ranged from Level I (meta-analysis of multiple controlled studies) to Level VI (opinions of respected authorities, or the opinions of an expert committee, including their interpretation of non-research-based information) (Stetler et al., 1998). The more rigorous level of evidence (Level I) reports evaluated the effectiveness of pharmacological interventions included in oral rinses and toothpastes in reducing oral bacterial flora, dental plaque, and dental caries. The lack of robust research evidence related to direct nursing practice of oral care in the pediatric critical care setting is significant for future research. Across the "best available evidence," three nursing interventions were identified for oral hygiene care in the pediatric critical care setting: 1) oral assessment, 2) mechanical interventions, and 3) pharmacological interventions.

Oral Assessment

A number of articles highlighted the importance of regular oral assessment to guide good oral care (Hayes & Jones, 1995, McNeill, 2000; O'Reilly, 2002). Barriers to consistent oral assessment include lack of time and lack of knowledge (McNeill, 2000). Hayes and Jones (1995) developed a simple mnemonic to guide oral assessment, the "Brushed" oral assessment tool. This instrument was modified by the addition of "Teeth" to form the "Brushed Teeth" oral assessment instrument (see Table 3). Conducting systematic, routine oral assessment prior to each oral hygiene care is a best practice recommendation. Similar to other nursing standardized assessments, research is needed to test the efficacy and efficiency of this instrument in practice.

Mechanical Interventions

Mechanical oral care interventions aim to physically remove dental plaque and debris from the oral cavity (Grap & Munro, 2004). Although nurses have used foam swabs for many decades, the toothbrush is more effective in removing dental plaque; however, success depends on how often the toothbrush is used and for what duration (Franklin et al., 2000; Pearson & Hutton, 2002). In a United Kingdom pediatric critical care setting where foam swabs were the most commonly used oral care tool, study results revealed a significant increase in mean dental plaque accumulation (p = 0.001) and gingivitis (p = 0.006) admission to discharge (Franklin et al., 2000). A small, soft toothbrush is recommended for intubated, dentate children (Munro & Grap, 2004). Current guidelines by the New Zealand Dental Association (2006) recommend that the gums of babies whose teeth have not yet erupted should be cleaned and moistened with a small, soft toothbrush or a gauze swab moistened with clean water or saline. A plain foam swab is recommended only to moisten the oral cavity or to apply mouth rinse.

Pharmacological Intervention

Pharmacological oral care interventions involve the use of topical applications to assist with plaque control and decontamination of the oropharynx. The anti-caries effect of fluoride results from its action on the tooth/plaque interface, promoting demineralization of early caries and reducing tooth enamel solubility (Marinho, Higgins, Logan, & Sheiham, 2003). Additional benefits include reducing the formation of plaque acids (O'Reilly, 2003). Use of fluoride in toothpaste and other products has been proven to reduce dental caries in children. A Cochrane Collaboration systematic review of over 42,300 children in 70 trials demonstrated an average reduction of 24% in decayed, missing, and filled tooth surfaces in children using fluoride toothpaste (95% confidence interval 21 to 28; p < 0.0001) (Marinho et al., 2003).

Fluoride concentrations as low as 400 parts per million of fluoride (ppm F) are available in children's toothpastes, but research suggests a fluoride concentration of at least 1000 ppm F is needed to reduce dental caries (Marinho et al., 2003). Rinsing out toothpaste following brushing has been found to decrease fluoride absorption and caries prevention (Ashley, Attrill, Ellwood, Worthington, & Davies, 1999; Chesnutt, Schafer, Jacobson, & Stephen, 1998). Thus, it is recommended that spitting out excess toothpaste rather than rinsing, or keeping rinsing to an absolute minimum, more effectively reduces caries (Ashley et al., 1999; Chesnutt et al., 1998; Marinho et al., 2003).

Chlorhexidine gluconate is a commonly used broad-spectrum antibacterial mouth rinse that decontaminates the oropharynx and reduces dental plaque (Grap & Munro, 2004; Houston et al., 2002; O'Reilly, 2003). The rinse is active against both gram negative and gram positive organisms, and there are no documented cases of microbial resistance (Grap & Munro, 2004). Once fixed to the oral surfaces, chlorhexidine gluconate is released between 8 to 24 hours. Thus, the 12-hourly (BD) use of chlorhexidine gluconate is recommended (O'Reilly, 2003).

Many nurses and other caregivers are unaware that sodiumlauryl phosphate and sodium monoflurophosphate present in the majority of toothpastes interact and inactivate the action of chlorhexidine gluconate mouth rinses (O'Reilly, 2003). Toothpaste and chlorhexidine gluconate mouth rinse are therefore not recommended to be used in conjunction with one another. Kolahi & Soolari (2006) recommend a time lapse of at least 30 minutes between using toothpaste and a chlorhexidine gluconate mouth rinse.

No serious side effects of chlorhexidine gluconate mouth rinse have been reported, but altered taste sensation, tooth discoloration, and tongue discoloration may occur. This tooth discoloration is easily removed by dental hygienists (Munro & Grap, 2004).

Numerous studies completed in children with cancer using an oral hygiene regime have recommended the use of a chlorhexidine gluconate mouth rinse because it reduces the severity of mucositis and alleviates oral discomfort (Cheng, 2004; Cheng, Molassiotic, Chang, Wai, & Cheung, 2001; Gibson & Nelson, 2000). A study in children with cancer between 6 and 17 years of age reported that children using chlorhexidine gluconate mouth rinse also found the taste acceptable and tolerable (Cheng, 2004).

No evidence was found to support the use of chlorhexidine gluconate mouth rinse in the PICU or adult ICU, or in cancer treatments in children under 6 years of age. For this reason, the guideline recommends that only children 6 years of age and older should use chlorhexidine gluconate 0.12% mouth rinse. Further research is needed to substantiate the use of chlorhexidine gluconate mouth rinse in children less than 6 years of age.

Two randomized controlled trials completed in adult cardiothoracic ICU patients have shown beneficial results from using twice-daily chlorhexidine gluconate mouth rinse in combination with twice-daily tooth brushing. DeRiso, Ladowski, Dillon, Justice, and Peterson (1996) found a significant reduction in the overall nosocomial infection rate (65%; p < 0.01), the incidence of total respiratory tract infections (69%; p < 0.05), and the need for intravenous antibiotics (43%; p < 0.05) for subjects in the chlorhexidine gluconate group. In another study, Houston et al. (2002) found patients who were intubated for more than 24 hours and in the chlorhexidine group had a 58% (p = 0.06) reduction in the incidence of nosocomial pneumonia. Review of the literature revealed that toothpaste containing fluoride and the use of chlorhexidine gluconate mouth rinse were the most effective products for oral care in the intensive care environment.

Sodium bicarbonate, hydrogen peroxide, and lemon and glycerine swabs are also available for oral care; however, research suggests their use may be harmful for patients (Hayes & Jones, 1995; Kite & Pearson, 1995; McNeill, 2000; Munro & Grap, 2004; O'Reilly, 2003). Hydrogen peroxide is used to break down debris and crusting within the oral cavity; however, it has been reported to cause superficial burns if diluted incorrectly (Hayes & Jones, 1995; O'Reilly, 2003). Sodium bicarbonate is recommended for cleansing the oral cavity and breaking down tenacious saliva, but like hydrogen peroxide, if not diluted sufficiently, it will cause superficial burns (Munro & Grap, 2004; O'Reilly, 2003). Lemon and glycerine swabs have been used for over 70 years and are considered a moistening agent; however, they initially stimulate saliva production but then cause rebound xerostomia. They are acidic and can cause irritation and demineralization of the tooth enamel (Hayes & Jones, 1995; Munro & Grap, 2004; O'Reilly, 2003). A moist oral mucosa is essential both for comfort and to reduce the symptoms of xerostomia. Clean water or normal saline are appropriate, inexpensive, widely available, and have minimal side effects (O'Reilly, 2003). McNeill (2000) suggests moistening the oral mucosa of intubated patients every two hours.

Practice Change: A Guideline for Oral Hygiene in the PICU

Synthesis of the above literature facilitated the development of an oral hygiene guideline for children in the PICU. The aims for the protocol were to a) increase nurses' knowledge of oral health and oral hygiene, b) maintain consistent and regular oral care, c) prevent complications from poor oral hygiene, d) reduce dental plaque and decontaminate the oropharynx, e) reduce the risk of infection (such as VAP), f) prevent tooth decay and gum disease, g) promote patient comfort--long and short-term, h) help strengthen developing teeth, i) educate children and their families about oral health, and j) encourage parents to be involved with their child's care where possible.

Two flowcharts were developed. The first flowchart (see Figure 2, Flowchart 1) guides care for children in the PICU who are intubated and at high risk of developing a nosocomial infection (such as VAP). This flowchart may also be used for children in the PICU who are not intubated, such as those who have a reduced level of consciousness and/or are NPO and/or may be dehydrated/ fluid restricted. The second flowchart (see Figure 2, Flowchart 2) relates to children who are able to eat and drink frequently. These children may also be able to participate in their own oral care, and their parents should be encouraged to help where possible.

Key points were also included in the guideline to prompt nurses where there may need to be a change or addition to the PICU oral care flowchart (see Figure 2). For example, the addition of Nystatin for oral thrush, or if the child is under the care of the oncology team, the Oncology Oral Care Chart provided by the Oncology Services may need to be used (Kolahni & Soolari, 2006). To complement the implementation of the guideline, a variety of oral care products appropriate for use in the PICU were sourced (see Figures 2 and 3).

Adding a new protocol does not ensure there will be a change in practice. The implementation of clinical change requires other processes, such as staff education and support (Powell, 2003). A month was dedicated to "oral hygiene in the PICU," during which various educational strategies were used to educate nurses about oral hygiene in the PICU and the new guideline. Educational strategies included an extensive education board, a note in the staff communication book, regular reminders at staff handover, a copy of the guideline on the clinical practice focus board, and a poster on the "what's news" notice board. Following the adoption of a change in practice, the 1998 Iowa Model (Titler et al., 2001) suggests that environmental, staff, fiscal, and patient and family variables need to be monitored and evaluated. Evaluation activities are ideally done locally. Suggested evaluation measures for this project include a post-implementation audit of the nurse's knowledge pertaining to oral hygiene in the PICU, an evaluation on the amount and cost of oral hygiene products ordered for the PICU, and an audit of nursing documentation of oral care.



Standardized oral hygiene practice has the potential to contribute to improved oral and general health of infants and children in the pediatric critical care setting. Equipped with better information, the right supplies, and practice recommendations, pediatric nurses can help ensure that children receive consistent, regular, and effective oral hygiene. More research in the pediatric critical care setting is needed to continue the development and establishment of evidence-based guidelines for oral hygiene.


Additional Readings

Grap, M.J., & Munro, C.L. (2004). Preventing ventilator-associated pneumonia: Evidence-based care. Critical Care Nursing Clinics of North America, 16(3), 349-358.


Adams, R. (1996). Qualified nurses lack adequate knowledge related to oral health, resulting in inadequate oral care of patients on medical wards. Journal of Advanced Nursing, 24(3), 552-560.

Ashley, P.E, Attrill, D.C., Ellwood, R.P., Worthington, H.V., & Davies, R.M. (1999). Toothbrushing habits and caries experience. Caries Research, 33(5), 40-402.

Brennan, M.T., Bahrani-Mougeot, E, Fox, P.C., Kennedy, T.P., Hopkins, S., Boucher, R.C., et al. (2004). The role of oral microbial colonization in ventilator-associated pneumonia. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, 98(6), 665-672.

Cheng, K.K.F. (2004). Children's acceptance and tolerance of chlorhexidine and benzydamine oral rinses in the treatment of chemotherapy-induced oropharyngeal mucositis. European Journal of Oncology Nursing, 8(4), 341-349.

Cheng, K.K.E, Molassiotic, A., Chang, A.M., Wai, W.C., & Cheung, S.S. (2001). Evaluation of an oral care protocol intervention in prevention of chemotherapy-induced oral mucositis in paediatric cancer patients. European Journal of Cancer, 37(16), 2056-2063.

Chestnutt, I.G., Schafer, F., Jacobson, A.P., & Stephen, K.W. (1998). The influence of toothbrushing frequency and post-brushing rinsing on caries experience in a caries clinical trial. Community Dental Oral Epidemiology, 26(6), 406-411.

Davies, R.M., Ellwood, R.P., & Davies, G.M. (2004). The effectiveness of a toothpaste containing reclose and polyvinylmethylethermaleic acid copolymer in improving plaque control and gingival health: A systematic review. Journal of Clinical Peridontology, 31(12), 1029-1033.

DeRiso, A.J., Ladowski, J.S., Dillon, T.A., Justice, J.W., & Peterson, A.C. (1996). Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and non-prophylactic systemic antibiotic use in patients undergoing heart surgery. Chest, 109(6), 1556-1561.

Durso, S.C. (2005). Oral manifestations of disease. In D.L. Kasper, A.S. Fauci, D.L. Longo, E. Brauwald, S.L. Hauser, & J.L. Jameson (Eds.), Harrison's principles of internal medicine (16th ed.) (pp. 194-201). New York: McGraw-Hill. Retrieved from library_resources/e-books/

Elward, A.M., Warren, D.K., & Fraser, V.J. (2002). Ventilator-associated pneumonia in pediatric intensive care unit patients: Risk factors and outcomes. Pediatrics, 109(5), 758-764.

Fitch, J., Munro, C., Glass, C., & Pellegrini, J. (1999). Oral care in the adult intensive care unit. American Journal of Critical Care, 8(5), 314-318.

Fourrier, F., Cau-Pottier, E., Boutigny, H., Roussel-Delvallez, M., Jourdain, M., & Chopin C. (2000). Effects of dental plaque antiseptic decontamination on bacterial colonization and nosocomial infections in critically ill patients. Intensive Care Medicine, 26(9), 1239-1247.

Fourrier, F., Duvivier, B., Boutigny, H., Roussel-Delvallez, M., & Chopin, C. (1998). Colonization of dental plaque: A source of nosocomial infections in intensive care unit patients. Critical Care Medicine, 26(2), 301-308.

Franklin, D., Senior, N., James, I., & Roberts, G. (2000). Oral health status of children in a paediatric intensive care unit. Intensive Care Medicine, 26(3), 319-324. Gibson. F., & Nelson, W. (2000). Mouth care for children with cancer. Paediatric Nursing, 12(1), 18-22.

Grap, M.J., Munro, C.L., Elswick, R.K., Sessler, C.N., & Ward, K.R. (2004). Duration of action of a single, early oral application of chlorhexidine on oral microbial flora in mechanically ventilated patients: A pilot study. Heart and Lung, 33(2), 83-91.

Hayes, J., & Jones, C. (1995). A collaborative approach to oral care during critical illness. Dental Health, 34(3), 6-10.

Houston, S., Hougland, P., Anderson, J.J., La Rocco, M., Kennedy, V., & Gentry, L.O. (2002). Effectiveness of 0.12% chlorhexidine gluconate oral rinse in reducing prevalence of nosocomial pneumonia in patients undergoing heart surgery. American Journal of Critical Care, 11(6), 567-570.

Institute for Healthcare Improvements (IHI). (2005). IHI campaign to save 100,000 lives, pediatric node: Preventing ventilator associated pneumonia. Retrieved from 2005/20050720_vap_webcast.pdf

Kite, K., & Pearson, L. (1995). A rationale for mouth care: The integration of theory with practice. Intensive and Critical Care Nursing, 11(2), 71-76.

Kolahi, J., & Soolari, A. (2006). Rinsing with chlorhexidine gluconate solution after brushing and flossing teeth: A systematic review of effectiveness. Quintessence International, 37(8), 605-612.

Marieb, E.N. (1998). Human anatomy and physiology (4th ed.). San Francisco: Benjamin Cummings Science Publishing.

Marinho, V.C.C., Higgins, J.P.T., Logan, S., & Sheiham, A. (2003). Fluoride toothpastes for preventing dental caries in children and adolescents. The Cochrane Database of Systematic Reviews 2003, 1(CD002278), 1-84.

McNeill, H.E. (2000). Biting back at poor oral hygiene. Intensive and Critical Care Nursing, 16(6), 367-372.

Millikan, J., Tait, G.A., Ford-Jones, E.L., Mindorff, C.M., Gold, R., & Mullins, G. (1988). Nosocomial infections in a pediatric intensive care unit. Critical Care Medicine, 16(3), 233-237.

Munro, C.L., & Grap, M.J. (2004). Oral health and care in the intensive care unit: state of the science. American Journal of Critical Care, 13(1), 25-34.

New Zealand Dental Association (2006). How to look after your child's teeth. Retrieved from http://www, htm

O'Reilly, M. (2003). Oral care of the critically ill: A review of the literature and guidelines for practice. Australian Critical Care, 16(3), 101-109.

Pearson, L.S., & Hutton, J.L. (2002). A controlled trial to compare the ability of foam swabs and toothbrushes to remove dental plaque. Journal of Advanced Nursing Practice, 39(5), 480-489.

Powell, C.V. (2003). How to implement change in clinical practice. Paediatric Respiratory Reviews, 4(4), 330-346.

Richards, M.J., Edwards, J.R., Culver, D.H., & Gaynes, R.P., & the National Nosocomial Infection Surveillance System. (1999). Nosocomial infections in paediatric intensive care units in the United States. Pediatrics, 103(4), e39. Retrieved from e39

Stetler, C.B., Brunell, M., Giuliano, K.K., Morsi, D., Prince, L., & Newell-Stokes, V. (1998). Evidence-based practice and the role of nursing leadership. Journal of Nursing Administration, 28(7-8), 45-53.

Thomson, W.M., Ayers, K.M.S., & Broughton, J.R. (2003). Child oral health inequalities in New Zealand: A background paper to the public health advisory committee. National Health Committee (May, 2003), 30-94. Retrieved from http://www.nhc. pdf

Titler, M.G., Kleiber, C., Steelman, V.J., Rakel, B.A., Budreau, G., Everett, L.Q., ... Goode, C.J. (2001). The Iowa model of evidence-based practice to promote quality care. Critical Care Nursing Clinics of North America, 13(4), 497-509.

Wong, D.L, Hockenberry-Eaton, M., Wilson, D., Winkelstein, L.M., Ahmann, E., & Divito-Thomas RA. (1999). Whaley & Wong's nursing care of infants and children (6th ed.). St Louis, MO: Mosby, Inc.

Lisa Johnstone, MHPrac, RN, is a Pediatric Nurse Educator, Bay of Plenty District Health Board, Tauranga, Bay of Plenty, New Zealand. At the time of the writing of this article, she was a Registered Nurse, Pediatric Intensive Care Unit, Starship Children's Hospital, Auckland, New Zealand.

Deb Spence, PhD, RM, RM, is the Joint Head of Nursing, the Auckland University of Technology, Auckland, New Zealand.

Jane Koziol-McClain, PhD, RN, is a Professor of Nursing, the Auckland University of Technology, Auckland, New Zealand.

Statement of Disclosure: The authors reported no actual or potential conflict of interest in relation to this continuing nursing education article.
Table 1.
Oral Hygiene Practice Survey (N= 47)
                                                             n    %

Is oral hygiene an essential task when caring for
children in the PICU?

[] Yes                                                       45   96
[] No                                                         2    4

"Oral hygiene is very important" (Likert Scale)

[] Strongly agree                                            38   81
[] Somewhat agree                                             8   17
[] Somewhat disagree                                          1    2

Have you ever received any form of education on
oral hygiene in the PICU?

[] Yes                                                       26   55
[] No                                                        21   45
[] Never read any literature or research on what
constitutes good oral hygiene.                               31   66

"The oral cavity is difficult to clean"

(Likert Scale)

[] Strongly agree                                            12   26
[] Somewhat agree                                            26   55

Do your oral hygiene cares vary for intubated
versus non-intubated children?

[] Yes                                                       40   85
[] No                                                         6   13
[] No Response                                                1    2
  Assess oral cavity once a shift [] Yes [] No               10   21
  Assess oral cavity prior to every oral care [] Yes [] No   29   62
  Used a foam swab for oral care [] Yes [] No                44   93

Please tick boxes that best describes your practice.
Do you use a toothbrush for oral care? [] Yes [] No          41   87
If yes, how often during a shift do you use a toothbrush
for oral care?

  [] Twice during a 12-hour shift                             8   17
  [] Once during a 12-hour shift                             23   49
Do you use chlorhexidine 0.2% mouth rinse for oral            5   11
hygiene cares?
  [] Yes [] No
If yes, how often do you use chlorhexidine 0.2%               4    9
mouth rinse?
  [] Q4 hourly                                               23   49
Do you use chlorhexidine 0.1 % mouth
rinse for oral hygiene cares?
  [] Yes [] No                                               13   28
If yes, how often do you use chlorhexidine                   39   83
0.1% mouth rinse?
  [] Q4 hourly
Do you use toothpaste? [] Yes [] No                          19   40
If yes, how often do you use it?                              4    9
  [] Once in 12 hours                                         4    9
  [] 04 hourly
  [] Never

What benefits might good oral hygiene provide?
(Please tick appropriate box)
  [] Patient comfort--short-term                             39   83
  [] Patient comfort--long-term                              38   81
  [] Plaque reduction                                        22   47
  [] Reduce risk of infection                                43   91
  [] Prevent tooth decay and gum disease                     33   70

Identified barriers that may prevent adequate oral
hygiene for children in the PICU. (Please tick
appropriate box)
  [] Oral ETT                                                15   32
  [] Maxillofacial surgery children                           6   13
  [] Lack of education                                        7   15
  [] Non-sedated child                                        4    9
  [] Unstable/critically ill                                 13   28
  [] Time/workload                                            4    9

Keen to learn more about oral hygiene in the PICU.
  [] Yes                                                     42   89
  [] No                                                       3    6
  [] No response                                              2    4

In support of an oral hygiene in the PICU guideline
being developed for the PICU.
  [] Yes                                                     46   98
  [] No                                                       1    2

Table 2.
Oral Care Studies

                        Objective, Sample
Author, Title,            Size, and Time
and Design                    Period                  Result

Cheng (2004)           To determine           Both oral rinses
                       acceptability and      accepted and
Prospective            tolerability of        tolerable.
Randomized             chlorhexidine (CHX)
Crossover Trial        and benzydamine oral   Children found CHX
                       rinse agents in        more helpful in
                       children 6 to 17       reducing mucositis and
                       years old              palliating discomfort
                                              associated with
                       n= 34 (6 to 16         mucositis.
                       years, mean age
                       =10.32 years)          Children older than 6
                                              years used CHX mouth
                       12-month period        rinse.

Cheng, Molassiotic,    To determine the       A 38% reduction in the
Cheng, Wai, &          effectiveness of a     incidence of oral
Cheung (2001)          preventative oral      mucositis in the
                       care protocol in       children enrolled in
Prospective            reducing               the oral care protocol
Comparative Study      chemotherapy induced   group.
                       oral mucositis in
                       children (6 to 17      Children older than 6
                       years old) with        years used CHX mouth
                       cancer                 rinse.

                       n = 42 (6 to 16
                       years, mean age =
                       10.3 years)

                       8-month period

Davies, Ellwood, &     To compare the         A toothpaste
Davies (2004)          effectiveness of       containing
                       triclosan/PVA/MA       triclosan/PVA/MA
Systematic Review      copolymer and          copolymer provide a
(of Randomized         fluoride dentifrices   more effective level
Trials)                in improving plaque    of plaque control
                       control and gingival   than a fluoride
                       health                 dentifrice.

                       16 trials reviewed

DeRiso, Ladowski,      To test the            Inexpensive and
j Dillon, Justice, &   effectiveness of       easily applied
Peterson (1996)        oropharyngeal          oropharyngeal
                       decontamination        decontamination with
Prospective,           (CHX) on nosocomial    CHX mouth rinse
Randomized,            infections in a        reduces total
Double-Blinded,        comparatively          nosocomial pneumonia
Placebo-Controlled     homogenous             (69%, p < 0.05).
Clinical Trial         population of          Also a reduction in
                       patients undergoing    the need for
                       heart surgery          prophylactic IV
                                              antibiotics by 43%
                       n= 353 (mean age =     (p < 0.05).
                       experimental group
                       64.1 years and
                       control group 63.5

                       10-month period

Fourrier, Cau-         To document in ICU     Oral decontamination
Pottier, Boutigny,     patients the effect    with 0.2% CHX
Roussel-Delvallez,     of dental plaque       decreases bacterial
Jourdain, & Chopin     antiseptic             colonization and may
(2000)                 decontamination on     be related to a
                       the occurrence of      reduction in the
Single Blind           plaque colonization    incidence of
Randomized             by aerobic             nosocomial infections
Comparative Study      nosocomial pathogens   in ventilated
                       and nosocomial         patients.

                       n = 60 (more than 18
                       years of age, mean
                       age treated group
                       51.2 years and
                       control group 50.4

                       13-month period

Founder, Duvivier,     To study the dental    Dental plaque and
Boutigny, Roussel-     status and             colonization increases
Delvallez, & Chopin    colonization of        during patients ICU
(1998)                 dental plaque by       stay. Dental plaque
                       aerobic pathogens      must be considered a
Prospective            and their relation     reservoir of coloniza-
Non-Randomized         with nosocomial        tion and nosocomial
Clinical Trial         infections in ICU      infection in ICU
                       patients               patients.

                       n=57 (18 to 83
                       years, mean age = 49

                       12-month period

Franklin, Senior,      To examine the         The present mouth care
James, & Roberts       dental status of       regime was ineffective
(2000)                 critically ill         in preventing a build
                       children in PICU and   up of plaque and
Prospective            determine the          maintaining gingival
Non-Randomized         efficacy of the        health. Significant
Control Trial          mouth care provided    increase in dental
                                              plaque accumulation
                       n = 54 (mean age 4.8   and gingivitis during
                       [+ or -] 4.3)          PICU admission.

                       6-month period

Grap & Munro           A summary of           VAP is a significant
(2004)                 specific risk          problem. Need EBP
                       factors associated     guidelines to reduce
Review Expert          with VAP and a         the incidence of VAP.
Opinion                summary of EBP         Further research is
                       recommendations for    warranted.

Hayes & Jones          Insight into how the   Implementation of an
(1995)                 oral care needs of     oral assessment tool.
                       the critically ill     Collaboration between
Expert Opinion         patient can be met     professions is needed
                                              to improve care for

Marinho, Higgins,      To determine the       Clear evidence that
Logan, & Sheiham       effectiveness and      fluoride containing
(2003)                 safety of fluoride     toothpaste has a
                       toothpaste in          caries inhibiting I
Systematic Review      preventing dental      effect--24% reduction.
(of Randomized or      caries in child/
Quasi-Randomized       adolescent
Controlled Trials)     less)

                       74 trials reviewed
                       (children aged 16 or

McNeill (2000)         Review of issues       Education on oral
                       surrounding oral       hygiene in ICU for ICU
Review Expert          hygiene in orally      nurses is needed.
Opinion                intubated patients     Research on oral
                                              hygiene regimes is

Munro & Grap           A review of oral       Combined use of
(2004)                 health and care in     toothbrush and paste
                       ICU                    and an antibacterial
Review Expert                                 mouth rinse may be
Opinion                                       beneficial. Additional
                                              research is warranted.

O'Reilly (2003)        What is the best       Regular oral
                       method of oral care    assessment,
Review Expert          for the critically     individualized patient
Opinion                ill patient in ICU?    care and the use of a
                                              oral care protocol is
                                              vital in order to
                                              provide good oral care
                                              for ICU patients.

Pearson & Hutton       To measure how         The foam swab is
(2002)                 effective foam swabs   ineffective in
                       are at removing        removing dental
Time Series            dental plaque when     plaque. A toothbrush
Cross-Over Trial       compared with using    is effective in
                       a toothbrush           removing dental

                       n = 34

Author, Title,                            (Stetler et
and Design                  Limits         al., 1998)

Cheng (2004)           Small sample           III
Crossover Trial

Cheng, Molassiotic,    Small sample           IV
Cheng, Wai, &          size
Cheung (2001)

Comparative Study

Davies, Ellwood, &     Adult                   I
Davies (2004)          population
                       Limitations for
Systematic Review      ICU as study
(of Randomized         time period at
Trials)                least 6
                       months and
                       patients are
                       seldom in ICU
                       for this long.

DeRiso, Ladowski,      Adult                  II
j Dillon, Justice, &   population
Peterson (1996)

Clinical Trial

Fourrier, Cau-         Small sample           II
Pottier, Boutigny,     size
Roussel-Delvallez,     Adult
Jourdain, & Chopin     population

Single Blind
Comparative Study

Founder, Duvivier,     Small sample           III
Boutigny, Roussel-     size
Delvallez, & Chopin    Adult
(1998)                 population

Clinical Trial

Franklin, Senior,      Small sample           III
James, & Roberts       size

Control Trial

Grap & Munro           Adult                  VI
(2004)                 population

Review Expert

Hayes & Jones          Adult                  VI
(1995)                 population

Expert Opinion

Marinho, Higgins,      Adult                   I
Logan, & Sheiham       population

Systematic Review
(of Randomized or
Controlled Trials)

McNeill (2000)         Adult                  VI
Review Expert

Munro & Grap           Adult                  VI
(2004)                 population

Review Expert

O'Reilly (2003)        Small                  VI
                       sample size
Review Expert

Pearson & Hutton       Adult                  III
(2002)                 population

Time Series
Cross-Over Trial

Table 3.
The "BRUSHED Teeth" Oral Assessment Tool

                       BRUSHED Teeth

B--Bleeding            Gums, mucosa, coagulation status?
R--Redness             Gums, stomatitis, tongue?
U--Ulceration          Size, shape, number, location, infected?
S--Saliva              Consistency, hyper/hyposecretion?
H--Halitosis           Character, acidotic, infected?
E--External factors    ETT tapes/ribbon, braces, angular cheilitis?
D--Debris              Plaque, thrush, foreign particles?
T-Teeth                Decay, loose, broken swelling abscess?

Source: Adapted with permission from Hayes & Jones, 1995.

Figure 2.
Oral Hygiene in the PICU Guideline

Objectives          * To prevent complications from poor oral
                      hygiene in the PICU
                    * To reduce dental plaque and decontaminate
                      the oropharynx
                    * To reduce the risk of infection (such as
                      ventilator associated pneumonia)
                    * To prevent tooth decay and gum disease
                    * To promote patient comfort--long and short-term
                    * To help strengthen developing teeth
                    * To maintain consistent and regular oral care
                      in the PICU
                    * To educate children and their families about
                      oral health
Responsibility      All Registered Nurses working in the PICU
Frequency           Please refer to the Flowcharts 1 and 2
Associated          The table below indicates other documents and
Documents           associated with this recommended best practice.

      Type                           Document Titles

 Company Policy                   Standard Precautions
Infection Control

 Journal article    Cheng (2004)
 Journal article    Cheng, Molassiotic, Chang, Wai, & Cheung (2001)
 Journal article    Davies, Ellwood, & Davies (2004)
 Journal article    DeRiso, Ladowski, Dillon, Justice, &
                      Peterson (1996)
 Journal article    Fourrier, Duvivier, Boutigny, Roussel-Delvallez,
                      & Chopin (1998).
 Journal article    Fourrier, Cau-Pottier, Boutigny, Roussel-
                      Delvallez, Jourdain, & Chopin (2000).
 Journal article    Franklin, Senior, James, & Roberts (2000)
 Journal article    Grap & Munro (2004)
 Journal article    Hayes & Jones (1995).
 Journal article    Marinho, Higgins, Logan, & Sheiham (2003)
 Journal article    McNeill (2000)
 Journal article    Munro & Grap (2004)
 Journal article    O'Reilly (2003)
 Journal article    Pearson & Hutton (2002)


Intubated and ventilated children in the PICU are dependent on
the health care team to tend to their everyday basic needs,
including oral hygiene. Poor oral hygiene has been associated
with increased dental plaque accumulation, bacterial colonization
of the oropharynx, and nosocomial infection rates, particularly
ventilator-associated pneumonia (VAP). Within 48 hours of
ICU admission the oropharyngeal flora undergoes change to a
more virulent flora that increases a patient's risk of developing
VAP (Munro & Grap, 2004). Research has suggested that reducing
the bacteria in the oropharynx reduces the pool of organisms
that may contaminate the lungs and cause VAP

An ETT provides a pathway for bacteria into the lungs. Many
drugs (inotropes, diuretics, anticonvulsants, anticholinergics,
antihistamines, antihypertensives, and sedatives/anaesthetic
agents) used in the PICU increase a child's risk of developing
xerostomia. Xerostomia is a decrease in salivary production,
which leads to a dry mouth and may impact on a child's overall
oral health (McNeill, 2000). Other factors that may impact on a
PICU child's risk of developing a nosocomial infection, such as
VAP, include:

* Fluid restriction

* Very young age

* Immunocompromised

* Decreased mobility

* Ineffective/absent gag and cough reflex

* Poor nutrition

* Naso/orogastric tube

* Supine position

Key Points

* Flowchart 1 (Figure 2) applies to all children except HDU
children that are eating and drinking regularly (full oral
intake) (Flowchart 2; Figure 3).

* Follow the flowchart as per your patient's age.

* If the patient is an oncology patient, you may need to refer to
the Paediatric Haematology/Oncology Oral Care Chart.

* Ensure Nilstat[R] is prescribed where indicated.

* If the patient experiences pain, swelling, or bleeding, inform
medical staff.

Equipment Available

* Gloves

* Plain foam swabs

* Soft paediatric toothbrush

* Oral suction brush

* Fluoride toothpaste
(Colgate Total[R])

* Chlorhexidine gluconate
0.2% (must be diluted 1:1
[10 ml chlorhexidine and
10 ml clean water])

* Gauze swabs

* Clean water

* 0.9% NaCL

* Syringe

* Yankeur suction

* Guedal/oral airway

* Vaseline[R]

* Mouth moisturiser

* Bite block

* Pupil torch (flashlight)
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Title Annotation:Continuing Nursing Education
Author:Johnstone, Lisa; Spence, Deb; Koziol-McClain, Jane
Publication:Pediatric Nursing
Article Type:Survey
Geographic Code:1USA
Date:Mar 1, 2010
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