DENVER — Attention to oral health in critically ill patients in the intensive care unit (ICU) is important for a variety of reasons, but it's not always top of mind.

Oral health can be a "neglected issue in critically ill adults," said nurse scientist Cindy Munro, RN, PhD, associate dean for research and innovation and professor at the College of Nursing at the University of South Florida in Tampa.

"There is more awareness now, but I think it's still a care process that gets pushed to the back burner when there are lots of other things going on. Sometimes urgent care does take priority over the routine," Dr. Munro told Medscape Medical News.

High Hopes

Dr. Munro gave the 2014 Distinguished Research Lecture — entitled Oral Health, Something to Smile About — here at the American Association of Critical-Care Nurses (AACN) 2014 National Teaching Institute and Critical Care Exposition.

For more than a decade, Dr. Munro's research has focused on the relation between oral health in critically ill adults and systemic disease. She has received more than $10 million in funding for her research, has published more than 100 articles, and is coeditor of the AACN's American Journal of Critical Care.

Optimal oral care not only promotes comfort and oral hygiene, it also has been shown reduce the risk for ventilator-associated pneumonia, one of the most common healthcare-associated infections, Dr. Munro said.

Oral health is as important as everything else we do for the patient.

Brushing teeth is unlikely to cut the risk for ventilator-associated pneumonia. What does make a difference is the application of chlorhexidine, which reduces the number of organisms in the mouth, she explained.

The standard protocol — outlined by the Institute for Healthcare Improvement as part of the ventilator bundle — is to use oral chlorhexidine antiseptic twice a day.

Dr. Cindy Munro

"I think nurses — me included — wanted toothbrushing to be really powerful in pneumonia prevention, and it turns out that it really is not," said Dr. Munro. However, "toothbrushing is important for a number of other reasons, like increasing patient comfort, reducing oral inflammation, reducing the risk of bacteremia, and reducing the risk of perhaps systemic inflammatory response," she added.

Currently, there are no evidence-based guidelines outlining how often the teeth of ICU patients should be brushed. "Toothbrushing varies from every 2 hours to only when it looks like they need it. Many hospitals now have guidelines about how often teeth should be brushed, but we really don't have any evidence base to support that," Dr. Munro explained.

She is planning a study to try to determine if "once, twice, or 3 times a day is optimal for balancing risk of toothbrushing with benefit of toothbrushing," she said.

"Toothbrushing is good for the removal of plaque and good oral health and gum care, but in terms of pneumonia, the only thing that has really been shown to be effective is chlorhexidine," said Mary Jo Grap, RN, PhD, Nursing Alumni Distinguished Professor, Adult Health and Nursing Systems, at the VCU School of Nursing in Richmond, Virginia.

"The reality is that oral health is as important as everything else we do for the patient. The critical care nursing community is on board with this now, and is embracing it because there has been so much literature on oral health and it really is a purely nursing function. It's something we can control independently; we don't have to have orders," said Dr. Grap.

The Distinguished Research Lectureship is funded by a grant from Philips Healthcare. Dr. Munro and Dr. Grap have disclosed no relevant financial relationships.

American Association of Critical-Care Nurses (AACN) 2014 National Teaching Institute and Critical Care Exposition. Presented May 19, 2014.


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