A Survey about Oral Care Practice Given by Nurses to... : Journal of Primary Care Dentistry and Oral Health (2025)

INTRODUCTION

Intensive care units (ICU) look after patients with severe life-threatening illnesses and injuries that require close monitoring.^[1] Unable to mobilize, patients in the ICU are dependent on caregivers for their daily chores. Patients in the ICU cannot maintain optimum oral hygiene. The failure to remove plaque leads to harbor of pathogenic organisms in the oral cavity. Oral bacteria can be accidentally aspirated into the respiratory tract of patients admitted to hospitals. This can lead to the development of systemic diseases such as pneumonia. Nosocomial pneumonia is the most common complication occurring in patients admitted to ICU.^[2] Hospital-acquired pneumonia is primarily a bacterial infection caused by Streptococcus pneumonia, H. influenza, P. aeruginosa, Enterobacter, Escherichia Coli, and others.^[3] The association between poor oral hygiene and nosocomial pneumonia has been documented in the previous literature.^[4-6]

Earlier studies had shown increased plaque formation on tooth, tongue, and other surfaces of the oral cavity.^[7-9] The bacterial count of dental plaque increases considerably during hospitalization in the ICU. The plaque and tongue coating increase with the long duration of stay in ICU. Effective plaque removal is pivotal for maintaining oral health and reduces the chances of infection. Good oral hygiene and oral health are essential to prevent the occurrence of infection. The implementation of optimal oral hygiene care to ICU patients can help reduce the incidence of infections.

The health workers involved in maintaining oral care are relatives, helpers, nurses, and others. Nurses are trained for oral care during their professional training course. However, the practice of oral healthcare delivery varies in hospitals. The present survey was aimed to study the oral healthcare practices delivered by the nurses in ICU patients admitted to hospital across Mumbai.

METHODOLOGY

This survey was conducted in the ICU of various hospitals across Mumbai. The survey included intensive care units (ICUs) across various specialties in the hospital, such as medical, surgical, and neurology ICUs. A total of 100 registered nurses working in the ICU of hospital in Mumbai were surveyed. The nurses who were registered with the medical council of India were interviewed in the survey.

A self-administered questionnaire was prepared to survey the awareness related to oral health care. The questionnaire consisted of 10 questions designed to assess the frequency of oral care and the types of equipment used, including cotton forceps, spatulas, toothbrushes, and other tools. The chemical agent, if used for plaque control, was identified. Any other aids or additional equipment provided by the hospital that facilitates oral hygiene was also evaluated. The data thus collected from the questionnaire were then analyzed.

DISCUSSION

The most common hospital infection is pneumonia (67%).^[10,11] Nosocomial pneumonia was as high as 34% of patients admitted to hospitals.^[12] The incidence of nosocomial in western India was reported to be 17%, with a mortality of 60%.^[13] The occurrence of nosocomial pneumonia complicates the condition of already depilated patients. This increases the number of days of stay in hospital.^[14]

The relationship between nosocomial pneumonia and periodontal disease has been studied in previous literature.^[15,16] The failure to maintain optimum oral hygiene leads to the formation of dental plaque. In a study conducted by Celik et al. nurses used tongue depressor and torch for oral examination. The intensive care were not using proper oral assessment methods. Standardized assessment tools should be taught and practiced by healthcare workers.^[17,18] Brazilian legislative chamber has approved a bill for the mandatory presence of dental professionals in the ICU. The importance of checkups by dental professionals in the ICU should be realized and made mandatory.^[19]

The American Association of Critical-Care Nurses recommends a complete oral hygiene program for critical care patients and acute care settings who are at high risk for ventilation-associated pneumonia to include:^[20]

1. Brushing teeth, gums, and tongue at least twice a day using a soft pediatric or adult toothbrush
2. Providing oral moisturizing gels to oral mucosa and lips every 2–4 h. Use of an oral chlorhexidine gluconate (0.12%) rinse twice a day during the preoperative period for adult patients who undergo cardiac surgery
3. The routine use of oral chlorhexidine gluconate (0.12% in other populations is not recommended by AACN

The implementation of critical oral care guidelines by the American Dental Association has significantly reduced the rate of infections in patients admitted in ICU. The mortality rate was decreased from 20% to 13.9%.^[21] Handa et al. reported that oral care protocol was effective in reducing the microbiological colony count of organisms such as Candida albicans and staphylococci.^[22]

This survey was conducted among nurses working in the ICU at various hospitals in Mumbai. Deposit on tooth and tongue surfaces in the oral cavity was observed in 94% of ICU patients. A large number of nurses were aware of the role of oral care in preventing complications. About 79% of the nurses were aware of the relationship between oral hygiene and nosocomial pneumonia. Agarwal et al. have reported similar findings of about awareness of the importance of oral care in 78% of nurses.^[23]

During the study, it was found that oral hygiene protocol differs in various hospitals. In this survey, 64% of nurses followed the standard protocol for oral hygiene maintenance. Our findings are similar to Alja’afreh et al. who revealed that 65% follow a specific oral care protocol.^[24] Ibrahim et al. reported that there was no formal unit protocol for assessment or provision of oral care for the ICU.^[25]

Nurses surveyed in hospitals preferred forceps and gauze (47%) over toothbrush (10%). Sreenivasan et al. found that 95% of the nurses surveyed use gauze soaked in chlorhexidine for oral care.^[26] The study conducted by Soh et al. found that 91% of nurses preferred using forceps and cotton for oral hygiene care.^[27] Aspiration vacuum was used by only 44% of nurses. The study cpnducted by Mirinda et al., reported that 76% of participants used aspiration vacuums for oral hygiene care. The reduce usage of aspiration vacuum was due to in availability in sufficient numbers.^[28]

The frequency of oral care varied across healthcare givers. According to Abidia., brushing every 12 h and using oral moisturizer every 2 h is recommended. In this survey, the frequency of oral care was twice daily in 45% of nurses.^[29] Chemicals agent most widely used among hospitals was chlorhexidine. Other agents were betadine, listerine, and hydrogen peroxide. 64% of the nurses in hospitals use chemical agents for cleaning oral cavity. In a study conducted by Turk et al., the most commonly used solution was sodium bicarbonate (79.2%).^[30] Chlorhexidine oral rinses is known to reduce ventilator-associated pneumonia.^[31-32] Chlorhexidine gel along with toothbrush was used previously to effectively reduce pneumonia.^[33]

Kelly’s 2023 survey included oral care methods such as tooth brushing 41%, foam sticks 3%, moisturizing the oral cavity 10% and mouth rinse with chlorhexidine and other oral care methods not specified.^[34]

After conducting this survey, it was concluded that soft toothbrush and chlorhexidine irrigation along with aspiration vacuum should be done twice daily for oral care. When a toothbrush cannot be used, the recommendation to use gauze soaked in chlorhexidine is a practical alternative for maintaining oral hygiene. The future impact of the enhancement of oral care measures in ICU should be studied.

CONCLUSION

In our survey, we came across that there was no uniformity in oral healthcare. The oral hygiene maintenance depends on the tools and equipment provided by hospitals. There are no clear guidelines regarding the specifications and requirements of oral care. It is indeed necessary to set stringent oral healthcare guidelines for healthcare givers. A standard protocol with the necessary material and equipment should be designed. Standardized oral care kits should be provided to all oral healthcare workers and nurses. Adequate training in proper usage of health care devices should be given. The incidence of hospital-acquired infections can be effectively reduced by providing optimal oral hygiene care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

REFERENCES