Disclaimer: This is a machine generated PDF of selected content from our databases. This functionality is provided solely for your convenience and is in no way intended to replace original scanned PDF. Neither Cengage Learning nor its licensors make any representations or warranties with respect to the machine generated PDF. The PDF is automatically generated “AS IS” and “AS AVAILABLE” and are not retained in our systems. CENGAGE LEARNING AND ITS LICENSORS SPECIFICALLY DISCLAIM ANY AND ALL EXPRESS OR IMPLIED WARRANTIES, INCLUDING WITHOUT LIMITATION, ANY WARRANTIES FOR AVAILABILITY, ACCURACY, TIMELINESS, COMPLETENESS, NON-INFRINGEMENT, MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. Your use of the machine generated PDF is subject to all use restrictions contained in The Cengage Learning Subscription and License Agreement and/or the Gale Virtual Reference Library Terms and Conditions and by using the machine generated PDF functionality you agree to forgo any and all claims against Cengage Learning or its licensors for your use of the machine generated PDF functionality and any output derived therefrom. Systematic literature review of oral hygiene practices for intensive care patients receiving mechanical ventilation Angela M. Berry, Patricia M. Davidson, Janet Masters and Kaye Rolls 16.6 (Nov. 2007): p552. Copyright: COPYRIGHT 2007 American Association of Critical-Care Nurses http://ajcc.aacnjournals.org/ Background Oropharyngeal colonization with pathogenic organisms contributes to the development of ventilator-associated pneumonia in intensive care units. Although considered basic and potentially nonessential nursing care, oral hygiene has been proposed as a key intervention for reducing ventilator-associated pneumonia. Nevertheless, evidence from randomized controlled trials that could inform best practice is limited. Objective To appraise the peer-reviewed literature to determine the best available evidence for providing oral care to intensive care patients receiving mechanical ventilation and to document a research agenda for this important activity in optimizing patients’ outcomes. Methods Articles published from 1985 to 2006 in English and indexed in the CINAHL, MEDLINE, Joanna Briggs Institute, Cochrane Library, EMBASE, and DARE databases were searched by using the key terms oral hygiene, oral hygiene practices, oral care, mouth care, mouth hygiene, intubated, mechanically ventilated, intensive care, and critical care. Reference lists of retrieved journal articles were searched for publications missed during the primary search. Finally, the Google search engine was used to do a comprehensive search of the World Wide Web to ensure completeness of the search. The search strategy was verified by a health librarian. Results The search yielded 55 articles: 11 prospective controlled trials, 20 observational studies, and 24 descriptive reports. Methodological issues and the heterogeneity of samples precluded meta-analysis. Conclusions Despite the importance of providing oral hygiene to intensive care patients receiving mechanical ventilation, high-level evidence from rigorous randomized controlled trials or high-quality systematic reviews that could inform clinical practice is scarce. (American Journal of Critical Care. 2007;16:552-563) ********** Although nurses recognize that oral hygiene is an integral part of care in intensive care units (ICUs), the relationship between oral hygiene and the reduction of oropharyngeal colonization with pathogenic organisms is less recognized.Clinical Practice Guidelines Revisions Writing Intensive Component of Course

The vulnerability of ICU patients to nosocomial infections underscores the importance of examining interventions and strategies to improve patients’ outcomes. Ventilator-associated pneumonia (VAP) is a leading cause of death due to nosocomial infection in ICUs. (1) VAP occurs in 9% to 28% of patients treated with mechanical ventilation, and mortality rates for VAP are from 24% to 50%. These figures may be higher in immunocompromised patients and when the pneumonia is caused by multiresistant pathogens. (1) Although the relationship between oral care and prevention of VAP is difficult to substantiate directly, oral hygiene is considered an important strategy in combination with a range of other activities, such as subglottal suctioning, for improving clinical outcomes. (2) In their guidelines for preventing healthcare-associated pneumonia, (2) the Centers for Disease Control and Prevention recommend the development and implementation of a comprehensive oral hygiene program, potentially with the inclusion of an antiseptic agent, for settings where patients are at risk for hospital-acquired pneumonia. In support of this recommendation, researchers (3,4) have advocated oral hygiene (and a subsequent reduction in the colonization of dental plaque) as an important strategy in preventing VAP. Despite these recommendations, limited evidence exists to guide nurses’ oral hygiene practice in the general ICU population. Most available evidence has been developed for oncology and cardiothoracic patients, and it is not apparent whether these guidelines are applicable to general intensive care patients. The omission of oral care in the ventilation bundle of the Institute for Healthcare Improvement challenges the recognition of the relationship between oral care and the development of VAP. The American Association of CriticalCare Nurses recently released a practice alert (5) that supports the importance of oral care in influencing outcomes in critically ill patients. Clearly, fundamental nursing practices such as hand hygiene, (2,6) semirecumbent positioning of patients, (2,7,8) subglottal suctioning, (8-12) and reducing colonization of dental plaque by respiratory pathogens (4,13,14) play a critical role in minimizing the incidence of VAP. Nurses admit that these elementary procedures are often relegated to a lower priority in the high-pressure, highly technological critical care environment. Such anecdotal reports are further substantiated by Grap et al, (15) who found that a sample of 77 healthcare providers perceived oral hygiene as less important than other unspecified nursing practices to patients’ well-being. Therefore, if nurses are to appreciate the relationship between dental plaque and its colonization with respiratory pathogens potentially leading to VAP, they must have a clear understanding of the complex characteristics of the oral cavity. The normal flora of the oral cavity may include up to 350 different bacterial species, (16) with tendencies for groups of bacteria to colonize different surfaces in the mouth. For example, Streptococcus mutans, Streptococcus sanguis, Actinomyces viscosus, and Bacteroides gingivalis mainly colonize the teeth; Streptococcus salivarius mainly colonizes the dorsal aspect of the tongue; and Streptococcus mitis is found on both buccal and tooth surfaces. (16) Because of a number of processes, however, critically ill patients lose a protective substance called fibronectin from the tooth surface. Loss of fibronectin reduces the host defense mechanism mediated by reticuloendothelial cells. (17) This reduction in turn results in an environment conducive to the attachment of organisms such as Pseudomonas aeruginosa to buccal and pharyngeal epithelial cells. (17) The proliferation of organisms depends to a large extent on their ability to attach to a surface in the mouth.Clinical Practice Guidelines Revisions Writing Intensive Component of Course

Bacteria that attach to the tooth surface gradually coalesce to produce a biofilm, and after further development lead to the formation of dental plaque, which is occupied by a diverse microcosm of organisms. (16) In summary, addressing the formation of dental plaque and its continued existence by optimizing oral hygiene in critically ill patients is an important strategy for minimizing VAP. Objectives The goals of this review were to evaluate peer-reviewed publications to determine the best available evidence for providing oral care to ICU patients receiving mechanical ventilation and to document a research agenda to improve patients’ outcomes. Method Approaches used to review the scientific literature range from a purposeful, systematic evaluation of rigorous studies to subjective overviews of descriptive articles. (18(p53)) Well-conducted systematic reviews can result in 3 major outcomes. First, increased power can be obtained by combining the effects of a number of smaller studies on the same topic when homogeneity allows meta-analysis. Second, systematic reviews to some extent enable the comparison of effects of studies with different designs. (18(p53)) Finally, a prospective and systematic review allows synthesis of the data and should assist in providing quality current evidence to guide clinical practice. (19) Formulation of the review question requires extensive background research to enable an informed outcome. The question must accurately reflect the extent of the issue to be reviewed. Therefore, a comprehensive approach, including a wide-ranging search of the literature together with consultation with experts, including nurses, in the field of dental health and critical care resulted in the following review question: With respect to intensive care patients receiving mechanical ventilation, what is the best method for providing oral hygiene that will result in a reduction of colonization of dental plaque with respiratory pathogens? Both experimental and nonexperimental study designs were included in the review. Because of the scarceness of review material on ICU patients receiving mechanical ventilation, articles that focused on specific oral care tools or solutions for the seriously ill also were included in the review. This review considered studies that included patients in ICUs who were intubated and receiving mechanical ventilation. Also included were studies that proposed a link between oral hygiene and systemic diseases. The interventions of interest were those designed to affect dental plaque specifically and oral hygiene in general. The types of outcome measures considered were general and specific indicators of oral health: * Microbial counts * Plaque indices * Oral assessment scores * Validation of tools used in the provision of oral care Articles were excluded if the study sample consisted of healthy participants or the study was done in a setting other than a critical care environment (eg, oncology). Articles published from 1985 to 2006 in English and indexed in the following databases were searched: CINAHL, MEDLINE, Joanna Briggs Institute, Cochrane Library, EMBASE, DARE, and the World Wide Web search engine, Google. Key search terms used in the review were oral hygiene, oral hygiene practices, oral care, mouth care, mouth hygiene, intubated, mechanically ventilated, intensive care, and critical care. This search strategy was verified by a health librarian. Clinical Practice Guidelines Revisions Writing Intensive Component of Course

Full copies of articles considered to meet the inclusion criteria (on the basis of their rifle, abstract, and subject descriptors) were obtained for data synthesis. Articles identified through reference lists and bibliographic searches were considered for data collection depending on the titles. Articles were independently selected according to prespecified inclusion criteria by 3 reviewers, each with a minimum of a master’s degree and certification in critical care. Discrepancies in the reviewers’ selections were resolved at meetings between the reviewers before the selected articles were included. Until recently, one system used to grade levels of evidence was based on work by the US Agency for Healthcare Research and Quality. Because of the increasing awareness of the limitations of that system, however, the classification structure was revised by the Scottish Intercollegiate Guidelines Network. Therefore, the rating method used for categorization of levels of evidence found in this review was based on the revised system (Tables 1 and 2). (20) Results Although we found a number of references for the provision of oral hygiene in the management of oncology and other medical patients, most articles related to critical care were review articles. For the prospective randomized control trials we found, metaanalysis could not be used to synthesize the results because of variations in the methods of these studies. For example, in some studies, the populations assessed differed, and for those studies in which the populations were the same, the interventions were often dissimilar. These limitations were recognized in a recent meta-analysis on the use of chlorhexidine and the incidence of nosocomial pneumonia. (21) Using the classification system developed by the Scottish Intercollegiate Guidelines Network, we reviewed 11 prospective controlled trials, (3,4,13,14,22-28) 20 observational studies, (15,29-47) and 24 descriptive studies. (21,48-70) The 11 articles on prospective controlled trials are presented in Table 3. Summary tables of the observational studies (Table 4) and descriptive papers (Table 5) are available only on the American Journal of Critical Care Web site (http://www.ajcconline.org) in the full-text view of this article. Discussion The information available for developing evidence-based guidelines is limited by the small number of randomized controlled studies and the heterogeneity of oral hygiene solutions, tools, and techniques. These limitations are compounded by a lack of reliable outcome measures to determine the effectiveness of the oral hygiene interventions. This lack of rigorous, quality studies markedly limits the weight of evidence presented and affects recommendations for practice. Despite these limitations, however, it is important to favor judgments regarding health benefits and reduction of harm over any possible cost considerations. (71) This literature review therefore is summarized as methodological issues, oral hygiene solutions and equipment, and oral health assessment strategies. Methodological Issues Electronic and hand searches do not completely reflect the extent of research outcomes. For example, trials reported at conferences are more likely than trials published in journals to contain negative reports. In addition, more positive than negative results tend to be reported in the literature. This failure to publish more studies with negative outcomes is due more to authors’ lack of inclination to submit such manuscripts than to the unwillingness of editors to accept such manuscripts. (72) Furthermore, many studies not published in English may not be included in the most commonly used searches. (73(p43)) These limitations lead to a risk for systematic reviews to yield a less-balanced analysis (18(p53)) and may therefore affect the recommendations resulting from the reviews. When we reviewed the 11 prospective controlled trials, a number of methodological issues became evident. First, the samples were taken from a range of critically ill patients. Some studies were limited to cardiac surgical patients, and even within these studies further variances occurred. For example, some participants remained in the study after extubation, thereby resulting in a mix of intubated and extubated patients with vastly different accessibility for the provision of oral hygiene.Clinical Practice Guidelines Revisions Writing Intensive Component of Course

The extubated patients were able to eat and drink fluids, (13) yet no allowance was made for the stimulation of saliva during mastication and the subsequent production of immune substances. Examples include substances such as immunoglobulin A, which obstructs microbial adherence in the oral cavity, and lactoferrin, which inhibits bacterial infection. (16) These important considerations may have influenced a study’s outcome. In their 2005 study, Fourrier et al (13) also did not permit the use of a toothbrush in the protocol, so in effect the control group received only a neutral gel for the provision of oral care. It is not surprising, therefore, that the trial group had a reduced colonization of dental plaque at day 10; one could argue that any form of oral hygiene is likely to produce a better result than none at all. A number of other researchers (3,4,14,22,26,27) also did not mention use of a toothbrush in their protocols. Liwu, (28) on the other hand, mentioned the use of swab sticks and reported that they were ineffective in removing debris between the teeth and gum borders. The protocol used by DeRiso et al (4) included a mint-flavored alcohol and water-based mouth rinse as the control versus a O. 12% chlorhexidine rinse. Although the placebo contained less than one-third the alcohol content of the chlorhexidine, the antiseptic properties of alcohol may have had an additional therapeutic effect. In the protocols of 2 studies, (27,47) hospital tap water was included as an oral rinse. Because hospital tap water is a source of nosocomial infections, (74,75) its use as an oral rinse in critically ill patients is questionable. Finally, the protocols of 3 studies (25(p174),27,28) included systematic oral assessment, but we were unable to ascertain whether the frequency of assessments and outcomes measures were similar in the studies or how these related to the oral hygiene provided to the study participants. Oral Hygiene Solutions and Equipment A range of oral rinse solutions and equipment are discussed in the literature, and these data and recommendations are briefly summarized here. * Chlorhexidinegluconate mouthwash is an antiplaque agent with potent antimicrobial activity that, without causing increased resistance of oral bacteria, is effective at low concentrations. (76) Chlorhexidine gluconate mouth rinse or gel has been used in a number of clinical trials, (3,4,14,22,26,77) primarily in cardiac surgery patients, to improve gingival health and to treat oral infections. Chlorhexidine mouth spray or rinse appears to be effective in reducing oral colonization of gram-negative bacteria and subsequent respiratory infections in cardiac surgical patients receiving mechanical ventilation in the ICU. (13) Also, significant cost savings and decreased mortality may be apparent for such patients. (4) Further research is required to determine the frequency of use of chlorhexidine and the relationship between chlorhexidine use and reduction in the incidence of VAP in the broader ICU population. Recommendation: B * Sodium bicarbonate mouth rinse is a cleaning agent that can dissolve mucus and loosen oral debris. (78) This rinse was used as a control substance in a study by Fourrier et al, (26) who compared it with a chlorhexidine gel. Although the frequency of colonization of plaque on day 5 was higher in the sodium bicarbonate group, by day 10 no significant difference could be detected between groups. To date, no reports of results of randomized controlled studies that support the use of sodium bicarbonate over any other mouth rinse in critical care patients have been published. Recommendation: Unresolved issue * Houston et al (3) used the essential oil mouth rinse Listerine (Pfizer, New York, New York) as a control when testing the effect of chlorhexidine mouth rinse. Other than that study, essential oils remain untested in ICU patients. Houston et al did not find any significant difference between chlorhexidine and Listerine with regard to cultures of sputum samples from postoperative cardiac patients with growth of microorganisms. Recommendation: Unresolved issue * Hydrogen peroxide mouth rinse has been used untested for many years in ICU patients. Although their study was excluded from this review because it included healthy participants, Tombes and Gallucci (79) found significant mucosal abnormalities in patients treated with hydrogen peroxide mouth rinse. Holberton et al (27) reported that some ICU patients found hydrogen peroxide mouth rinse distasteful and refused to use it. The effectiveness of foam sticks impregnated with hydrogen peroxide also has not been rigorously tested for the provision of oral hygiene in critically ill patients. Recommendation: Unresolved issue * Ph …Clinical Practice Guidelines Revisions Writing Intensive Component of Course