Oral Care Techniques Research Articles

Oral Management by a Full-Time Resident Dentist in the Hospital Ward Reduces the Incidence of Pneumonia in Patients with Acute Stroke.

Background A full-time dentist was assigned to a ward at our hospital to improve the quality of oral healthcare for hospitalized patients. A dental care system (DCS) was created to facilitate the collaboration between the full-time dentist and the nursing department. Objective To investigate the effects of DCS implementation on the incidence of pneumonia in patients with acute stroke. Methods This retrospective cohort study comprised 945 hospitalized acute stroke patients categorized into three groups: pre-, during-, and post-DCS. The DCS comprised dentist-led lectures and practical sessions, oral assessments, standardized oral care techniques, and information on the procedures for nurse-requested dental intervention. Data were extracted from the Japanese Diagnosis Procedure Combination database and medical records. The attributes of the patients, incidence of pneumonia, and number of patients who requested dental intervention were determined. Results The odds ratios of pneumonia onset were 3.16 (95% confidence interval [CI], 1.65–6.05; P = 0.001) in the pre-DCS and 2.80 (95% CI, 1.48–5.31; P = 0.002) in the during-DCS group compared with the post-DCS group, thereby confirming the effect of DCS on the incidence of pneumonia. The number of dental requests in the post-DCS group was noted to be higher than that in the pre-DCS group (P = 0.002). Conclusion Oral management by a full-time dentist was found to be effective in reducing the incidence of pneumonia in patients with acute stroke. To implement the best oral care practices in the hospital wards, the full-time dentist should work as a member of the medical team.

Refining an Oral Health Care Partner Intervention Using Behavior Change Techniques

Following a pilot, we refined an oral health carepartner intervention for individuals with mild dementia (IMD). In this intervention, we use behavior change techniques (BCTs) to foster changes by carepartners including using new oral-care techniques and developing skills for using cueing and communications approaches to support behavior changes by IMD (duration and frequency of toothbrushing and oral-hygiene skills); thus, improving plaque and gingival indices. We describe our approach to refining the intervention manual including a) completing the self-paced BCT taxonomy course, b) developing a coding schema, c) coding the original manual for evidence of BCTs, and d) refining the manual to improve use of BCTS in the refined intervention. Our results detail how BCTs can be applied to refine and improve interventions. This research demonstrates the value in using BCTs for interventions to address how carepartners and IMD can collaborate to improve oral hygiene care.

British Association of Critical Care Nurses: Evidence-based consensus paper for oral care within adult critical care units.

Patients who are critically ill are at increased risk of hospital acquired pneumonia and ventilator associated pneumonia. Effective evidence based oral care may reduce the incidence of such iatrogenic infection. To provide an evidence-based British Association of Critical Care Nurses endorsed consensus paper for best practice relating to implementing oral care, with the intention of promoting patient comfort and reducing hospital acquired pneumonia and ventilator associated pneumonia in critically ill patients. A nominal group technique was adopted. A consensus committee of adult critical care nursing experts from the United Kingdom met in 2018 to evaluate and review the literature relating to oral care, its application in reducing pneumonia in critically ill adults and to make recommendations for practice. An elected national board member for the British Association of Critical Care Nurses chaired the round table discussion. The committee focused on 5 aspects of oral care practice relating to critically ill adult patients. The evidence was evaluated for each practice within the context of reducing pneumonia in the mechanically ventilated patient or pneumonia in the non-ventilated patient. The five practices included the frequency for oral care; tools for oral care; oral care technique; solutions used and oral care in the non-ventilated patient who is critically ill and is at risk of aspiration. The group searched the best available evidence and evaluated this using the Grading of Recommendations Assessment, Development, and Evaluation system to assess the quality of evidence from high to very low, and to formulate recommendations as strong, moderate, weak, or best practice consensus statement when applicable. The consensus group generated recommendations, delineating an approach to best practice for oral care in critically ill adult patients. Recommendations included guidance for frequency and procedure for oral assessment, toothbrushing, and moisturising the mouth. Evidence on the use of chlorhexidine is not consistent and caution is advised with its routine use. Oral care is an important part of the care of critically ill patients, both ventilated and non-ventilated. An effective oral care programme reduces the incidence of pneumonia and promotes patient comfort. Effective oral care is integral to safe patient care in critical care.

Reducing Ventilator Associated Pneumonia in the NICU through oral care education: A quality improvement project

BackgroundInadequate oral care in the Neonatal Intensive Care Unit (NICU) can lead to Ventilator Associated Pneumonia (VAP). VAP rate was reported at 2.52 per 1000 ventilator days for the 12 months prior to intervention. A root cause analysis of VAPs during this period revealed only 70% compliance with oral care. VAP contributes to higher costs for the hospital, patient pain and suffering, morbidity and mortality, length of time on mechanical ventilation and increased hospital length of stay. This Quality Project aims to reduce VAP in the NICU through multidisciplinary re-education on the importance of oral care, and fostering an interdisciplinary oral care team of Respiratory Therapists and Registered Nurses. MethodAn IRB approved interventional pre and post intervention review of VAP rate was conducted on intubated neonatal patients from June 1, 2015–May 31, 2017. Intervention consisted of education perform as an interdisciplinary oral care team. Education was coordinated between Respiratory (RT) and Nursing (RN) educators, Lactation, and unit leaders to ensure standardized education to all staff. An oral care poster was created and presented to both RT and NICU RN staff at department meetings. An oral care PowerPoint was created and sent to all NICU RN's and was required as annual mandatory education for all RT's. Encouragement was provided through random chart audits from June 2016–May 2017, praising staff that coordinated care, and reminding staff who did not through friendly face to face interaction and email of the importance of routine, coordinated oral care. ResultsNICU VAP rates dropped during June, and came back up in July 2016 and dropped again in March 2017. Chart review revealed insufficient oral care (72% and 78%) in the two days prior to VAP events. Oral Care poster and education were re-introduced in August 2016 and April 2017. NICU VAP rates post intervention, June 2016–May 2017, was reported as 0.78 per 1000 ventilator days. ConclusionsIdentifying the primary factor through VAP root cause analysis made us aware of a VAP bundle component that was not being routinely followed. Having identified oral care as a problem in our unit enabled us to form an educational intervention with a standardized oral care technique that was effective in increasing the frequency and efficacy of oral care. Utilizing a multidisciplinary team for oral care fosters a sense of importance and responsibility to the staff and improved collaboration in care.

Raffinose Induces Biofilm Formation by Streptococcus mutans in Low Concentrations of Sucrose by Increasing Production of Extracellular DNA and Fructan

Streptococcus mutans is the primary etiological agent of dental caries and causes tooth decay by forming a firmly attached biofilm on tooth surfaces. Biofilm formation is induced by the presence of sucrose, which is a substrate for the synthesis of extracellular polysaccharides but not in the presence of oligosaccharides. Nonetheless, in this study, we found that raffinose, which is an oligosaccharide with an intestinal regulatory function and antiallergic effect, induced biofilm formation by S. mutans in a mixed culture with sucrose, which was at concentrations less than those required to induce biofilm formation directly. We analyzed the possible mechanism behind the small requirement for sucrose for biofilm formation in the presence of raffinose. Our results suggested that sucrose contributed to an increase in bacterial cell surface hydrophobicity and biofilm formation. Next, we examined how the effects of raffinose interacted with the effects of sucrose for biofilm formation. We showed that the presence of raffinose induced fructan synthesis by fructosyltransferase and aggregated extracellular DNA (eDNA, which is probably genomic DNA released from dead cells) into the biofilm. eDNA seemed to be important for biofilm formation, because the degradation of DNA by DNase I resulted in a significant reduction in biofilm formation. When assessing the role of fructan in biofilm formation, we found that fructan enhanced eDNA-dependent cell aggregation. Therefore, our results show that raffinose and sucrose have cooperative effects and that this induction of biofilm formation depends on supportive elements that mainly consist of eDNA and fructan.IMPORTANCE The sucrose-dependent mechanism of biofilm formation in Streptococcus mutans has been studied extensively. Nonetheless, the effects of carbohydrates other than sucrose are inadequately understood. Our findings concerning raffinose advance the understanding of the mechanism underlying the joint effects of sucrose and other carbohydrates on biofilm formation. Since raffinose has been reported to have positive effects on enterobacterial flora, research on the effects of raffinose on the oral flora are required prior to its use as a beneficial sugar for human health. Here, we showed that raffinose induced biofilm formation by S. mutans in low concentrations of sucrose. The induction of biofilm formation generally generates negative effects on the oral flora. Therefore, we believe that this finding will aid in the development of more effective oral care techniques to maintain oral flora health.

Oral decontamination techniques and ventilator-associated pneumonia.

Ventilator-associated pneumonia (VAP) is one of the major nosocomial infections in the intensive care unit (ICU), contributing to increased mortality and morbidity. Studies have shown that oral decontamination through the use of mechanical and pharmacological agents significantly reduces the incidence of VAP, but oral care practices in ICUs are not consistent. A double-blind randomised controlled trial was undertaken in the medical ICU of a tertiary care centre in India, to assess the efficacy of a toothbrush-based oral care technique in reducing incidence of VAP. Tooth-brushing with concurrent suctioning technique was not proved to be superior to mouth-swabbing. The greatest risk factor for developing VAP was the number of ventilator days (length of time on a ventilator). There was a statistical association between gender and presence of antibiotics with VAP.

Impact of routine oral care on opportunistic pathogens in the institutionalized elderly.

Routine oral hygiene is important for the control of opportunistic pathogens in the oral cavity of institutionalized elderly individuals. We evaluated the effects of routine oral care on opportunistic pathogens at various time points after admission to a nursing home. Twenty-five elderly subjects living in the nursing home (mean age: 86.0 +/- 10.4 years) participated in the study. Caregivers and dental hygienists cleaned the teeth, dentures, tongue, and mucosa after each meal using both routine and professional oral care techniques. Opportunistic pathogens were collected from the teeth, tongue, and mucosal surfaces using a cotton swab; and the species of microbes were determined and the numbers were counted following cultivation on selective agar. Regular oral care including professional oral care was found to be effective for reducing infections by many kinds of opportunistic pathogens on the teeth surfaces and the oral environment without food residue during a long-term study (6 months). Further, this care after 1 month significantly reduced infections by opportunistic pathogens on mucosal surfaces in subjects without dentures; however, this was not observed in those with dentures. Our data shows the importance of regular oral care in cleaning hard and soft surfaces of the oral cavity improves the oral health of the institutionalized elderly.

Achievement of oral care technique improvement by nurses using the oral care manual through respiratory support team activity

Achievement of oral care technique improvement by nurses using the oral care manual through respiratory support team activity

Feasibility of implementing oral health guidelines in residential care settings: views of nursing staff and residential care workers

PurposeTo determine the views of nurses and on the feasibility of implementing current evidence-based guidelines for oral care, examining barriers and facilitators to implementation. ResultsThis mixed-methods study involved an online survey of 35 nurses and residential care workers, verified and expanded upon by one focus group of six residential care workers. Results reflected that nurses and residential care workers (a) have little or no training in recommended oral care techniques, and (b) lack access to the equipment and professional supports needed to provide adequate oral care. Basic oral care might be performed less than once per day in some settings and patients with problematic behaviours, dysphagia, or sensitivities associated with poor oral health might be less likely to receive oral care. While lack of time was highlighted as a barrier in the survey findings, focus group members considered that time should not be a barrier to prioritising oral care practices on a daily basis in residential care settings. ConclusionThere are several important discrepancies between the recommendations made in evidence-based guidelines for oral care and the implementation of such practices in residential care settings. Nursing and residential care staff considered adequate oral care to be feasible if access, funding and training barriers are removed and facilitators enhanced.

The necessity of respiratory support team to improve oral care technique and issues of further development

The necessity of respiratory support team to improve oral care technique and issues of further development

The development of a feeding, swallowing and oral care program using the PRECEDE-PROCEED model in an orphanage-hospital in Guatemala

Purpose: The purpose of this study was to evaluate a long-term on-going international academic service-learning (I-ASL) intervention. Its goal was to improve swallowing, feeding and oral care technique of medical staff in an orphanage in Guatemala to children who are medically complex and have special needs.Method: The PRECEDE-PROCEED model was used as the conceptual framework of the program. Five major target areas were identified during the diagnosis, assessment, implementation and evaluation phases of the model: knowledge and skills, feeding equipment, feeding and oral care technique, positioning and communication. Verbal instruction, modelling and small group training was provided by the research team across all visits. A five-day intervention designed to increase feeders’ knowledge of feeding and oral care technique, signs and symptoms and complications of dysphagia and to improve their feeding, positioning and oral care technique was implemented and evaluated.Result: Statistical analyses showed significant increases in knowledge and appropriate feeding, positioning and oral care technique.Conclusion: As a consequence of the intervention, a trusting and mutually supportive relationship was built between the I-ASL team and the host organization.

Fundamental basis of patient-specific caries prevention

Clinical introduction of methods for personalized preventive medicine, it is essential to unravel biochemical components and ultastructural features of hard dental tissues. Accordingly, utilizing a variety of techniques and protocols (e.g., electron probe microanalysis, atomic-powered tunnel electron microscopy), the essential structural features of enamel (e.g., “enamel bridges” and “enamel tunnels”) have been identified. These studies have also led to our better understanding of some metabolic processes in teeth. Detection of previously unrecognized structures in enamel and dentin has helped explain the selectivity of chemical elements and their actions in the context of preventive means and the necessity of personalization of carious and not carious teeth diseases prevention. Our studies suggest that “enamel tunnels” play a major role in exchange processes between the tooth enamel and oral fluid stimulating mineral penetration of the dental enamel by molecular substances and microorganisms (i.e. functioning as a tissue barrier). Therefore, the enamel surface must be kept unexposed and the tooth openings must be treated to prevent its morphochemical alterations. The protective zone is non-cariogenic dental plaque sublimating necessary organic and inorganic components of the oral fluid. It appears difficult to accumulate this “plaque” but it becomes possible with the preventive means. Therefore, it is imperative to improve the professional oral care techniques in order to determine an acceptable level of caries prevention efficiency.

Abstract 2666: Oral Care Protocol Reduces Risk of Aspiration Pneumonia in Acute Stroke Patients

Background: Swallowing is a complex process. Dysphagia, or impaired swallowing, may result in aspiration and can significantly contribute to morbidity and mortality. Approximately 25-70% of patients with stroke have dysphagia. Dysphagia and dependency for feeding/oral care are important risk factors in the development of aspiration pneumonia, which can delay patient functional recovery. Hospital acquired pneumonia (HAP) prevention studies have focused on critical care environments with intubated patients. Far fewer studies have investigated non-intubated patients, however the same physiologic principles apply. Purpose: The purpose of this program is to present an evidence-based practice initiative implemented utilizing ventilator-associated pneumonia (VAP) oral care techniques in the non-intubated, at risk stroke population. Methods: A multidisciplinary educational approach was utilized to implement a comprehensive oral care program recommended by the Centers for Disease Control and Prevention (CDC). Care practices include all patients, regardless of mental status, have their teeth brushed at least twice daily. Additionally, patients at risk who are eating, have their teeth brushed prior to meals and then mouth cleansed and moisturized after meals. Patients with altered mental status who are NPO receive oral care every 2-4 hours using swabs/cleanser and moisturizer. Results: Aspiration pneumonia rate of stroke patients on the neuro/stroke unit was tracked. Pre-implementation aspiration pneumonia rates were 4% (128 patients). Post implementation aspiration pneumonia rates were reduced to 1.4% (268 patients). Conclusion: Prevention of hospital acquired pneumonia is essential and has been shown to improve outcomes. A team approach is vital in providing oral care and preventing potential aspiration pneumonia. A nursing-led research study will be undertaken to further explore this topic.

Reducing the incidence of stomatitis using a quality assessment and improvement approach

Stomatitis occurs in approximately 40% of the patients receiving systemic administration of chemotherapy and cancer treatments such as radiation to the head and neck. The presence of stomatitis affects the course of treatment and a patient's quality of life. An oncology nursing unit developed a quality assessment and improvement indicator addressing stomatitis. Oral cavity screening, dental consultations, oral care techniques, and patient teaching were included in the nursing interventions, which resulted in a marked reduction of new cases of stomatitis.