Oral hygiene care in the pediatric intensive care unit: practice recommendations.
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).
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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.
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.
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 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 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.
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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.
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 http://www.aut.ac.nz/library/ 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 http://www.chca.com/mm/webcasts/ 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, nzda.org.nz/public/kids. 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 http://pediatrics.org/cgi/content/full/103/4/ 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. govt.nz/publications/PDFs/chldoralhth. 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 years) 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. infections n = 60 (more than 18 years of age, mean age treated group 51.2 years and control group 50.4 years) 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 years) 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. prevention 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 patients. 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 population 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 warranted. 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 Level Author, Title, (Stetler et and Design Limits al., 1998) Cheng (2004) Small sample III size Prospective Randomized Crossover Trial Cheng, Molassiotic, Small sample IV Cheng, Wai, & size Cheung (2001) Prospective 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) Prospective, Randomized, Double-Blinded, Placebo-Controlled Clinical Trial Fourrier, Cau- Small sample II Pottier, Boutigny, size Roussel-Delvallez, Adult Jourdain, & Chopin population (2000) Single Blind Randomized Comparative Study Founder, Duvivier, Small sample III Boutigny, Roussel- size Delvallez, & Chopin Adult (1998) population Prospective Non-Randomized Clinical Trial Franklin, Senior, Small sample III James, & Roberts size (2000) Prospective Non-Randomized Control Trial Grap & Munro Adult VI (2004) population Review Expert Opinion Hayes & Jones Adult VI (1995) population Expert Opinion Marinho, Higgins, Adult I Logan, & Sheiham population (2003) Systematic Review (of Randomized or Quasi-Randomized Controlled Trials) McNeill (2000) Adult VI population Review Expert Opinion Munro & Grap Adult VI (2004) population Review Expert Opinion O'Reilly (2003) Small VI sample size Review Expert Opinion 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 sources 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) Overview 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 (Toothette[R]) * 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|
|Date:||Mar 1, 2010|
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