How to Perform Effective Oral Care for

Aspiration Pneumonia Prevention

by Karen Sheffler, MS, CCC-SLP, BCS-S, at SwallowStudy.com

Only 16% of nurses reported that they brush a patient’s teeth every 4 hours, and 33% reported brushing “rarely or not at all” (Cason, et al, 2007). However, this dolphin is receiving good oral care with an electric toothbrush!

We have explored the many reasons WHY the mouths of critically ill patients need good oral care to prevent pneumonia (see Part I, Part II, and Part III of Oral Hygiene and Aspiration Pneumonia Prevention).

Poor oral health not only can cause pneumonia, but it has also been linked to systemic infections, brain abscesses, cardiovascular disease, valvular heart disease, MI, CVA, poor glycemic control in diabetics, and joint infections (NICHE 2009).

Now we need to answer WHEN and HOW to provide good oral care.

WHEN TO PERFORM ORAL CARE:

Of course, the answer is on every patient, every shift, every day.

Is that realistic? Do we need to specifically target high-risk patients with a screening tool (similar to the stroke swallow screen)?

To do that, the medical team needs to examine the mouth. We know the typical Health and Physical exam performed by the doctor includes sticking out the tongue to say “ah”, but are the teeth, tongue, gums, and hard palate fully examined?

The Speech-Language Pathologist fully evaluates the structure and function of the oral cavity. We can share our critical findings with the team, but nurses and physicians can use screening tools to trigger at-risk patients.

One tool is the Kayser-Jones Brief Oral Health Status Examination (BOHSE). This screens:

• lips, tongue, tissues inside the cheek and floor/roof of mouth
• gums between the teeth and/or under dentures
• condition of natural teeth and/or artificial teeth
• posterior teeth pairs for chewing
• oral cleanliness.

This tool triggers when further evaluation is necessary by a dentist. Furthermore, it could highlight when the oral hygiene protocol needs to be activated and when dental issues may be a primary source of infection and disease. This should trigger the need for oral care every shift, using a suction toothbrush and a mouthwash. It could also trigger placement of the patient on aspiration precautions. This should at least include elevation of the head of the bed to 45 degrees at all times, unless contraindicated (i.e., per orders by neurologist, patients on ECMO, or other documented reasons).

HOW TO PERFORM ORAL CARE:

Print this PDF: Oral Care Procedures for Aspiration Pneumonia Prevention

Hospitals and healthcare institutions need to have written oral hygiene policies with step-by-step protocols based on the latest research.

Only 56% of hospitals (per one survey of nurses) have written oral hygiene protocols (Cason, et al, 2007). These researchers commented that their numbers may even be worse in reality due to a selection bias. Surveys were only distributed at educational seminars to nurses who were actively involved in educational opportunities.

In 2003, the CDC updated its guidelines for preventing health-care-associated pneumonia (nosocomial pneumonia). They state that it is “prudent for health-care facilities to implement” a comprehensive oral-hygiene program (page 12). The CDC indicated that more randomized-controlled studies are needed, but recommended at least frequent toothbrushing and swabbing with an antiseptic agent.

Standards-of-care or “care bundles” are now widely accepted in the ICU to prevent Ventilator Acquired Pneumonia. However, there is frequently little focus on oral care if you are not ventilated, and there is typically no continued focus on oral care after you are transferred out of the ICU to the medical or surgical floors.

Tools For Oral Care: What is effective?

1. Foam swabs and lemon-glycerin swabs are NOT effective!

Foam-swabbing alone increased the plaque and gingivitis over a 1-week trial period (Addems et al, 1992). Foam swabs cannot be considered an effective substitute for a toothbrush (Addems, et al, 1992; Ransier, et al, 1995).

However, to this day most hospitalized patients only receive oral care with a swab dipped in a 1.5% Hydrogen peroxide solution.

Note: Foam swabs may be needed in patients with a bleeding risk from a low platelet count (thrombocytopenia) or with mucositis. See the special section on mucositis below.

Lemon-glycerin swabs should never be used on older adult patients, as they can cause more harm than good. Lemon-glycerin swabs cause erosion of tooth enamel and can change the pH to 2-4 (too acidic). See Part II of Oral Hygiene and Aspiration Pneumonia Prevention regarding salivary pH.

2. Hydrogen Peroxide: Is it an adequate oral rinse?

Hydrogen Peroxide is a germicidal and a mechanical cleanser due to the characteristic foaming action.

However, Tombes & Gallucci (1993) noted the following adverse findings:

• Promotes fungal overgrowth (i.e., Candida species/”thrush”)
• Subjective complaints, especially unpleasant taste and mouth discomfort
• Inhibits mucosal healing in patients with oral lesions

3. Chlorhexidine Gluconate (CHG) for Oral Care and Aspiration Pneumonia Prevention:

Chlorhexidine Gluconate is a broad-spectrum antimicrobial, which can also target Candida species. CHG is particularly effective against bacteria that cause gingivitis. It has substantivity, meaning it lasts 12 hours or more in the oral cavity.

The Institute for Healthcare Improvement’s Protecting 5 Million Lives From Harm Campaign included recommendations to “develop a comprehensive oral care process that includes the use of 0.12% chlorhexidine oral rinse.”

Avoid CHG if:

• Hypersensitivity occurs (look for oral irritation or local allergic reaction)
• Under 18 years of age
• Pregnant, as studies in pregnant women have not been done. The label states to use only if clearly necessary.
• Periodontitis, as the effects on periodontitis have not been determined, and it may increase tartar (calculus formation).

Side effects:

• Staining oral surfaces, especially on unremoved plaques.
• Changes in taste perception. Apply after meals.

The hallmark study from DeRiso et al (1996) showed that 0.12% CHG rinse decreased incidence of nosocomial respiratory tract infections in patients who had cardiac surgery. Whereas, Bellissimo-Rodrigues et al (2009) performed a randomized, double-blind, placebo-controlled trial on Brazilian patients in ICU beds with length of stay >48 hours. No difference was found in the incidence of respiratory tract infection in groups with CHG solution versus a placebo solution. There were 21 episodes of infection in 19 out of the 98 patients in the CHG-group. There were 25 episodes of infection in 20 of the 96 patients in the placebo-group. However, the CHG-group did have a significantly delayed onset of the first respiratory tract infection. Interestingly, the authors noted that the oral health of many of the patients was poor at the start, and periodontal disease is present in 78% of Brazilian adults per a survey at that time. Periodontal disease may create a major reservoir for microbes that cannot be reached by the application of chlorhexidine. CHG may not be effective on periodontitis per the manufacturer. Another issue was that both groups received the CHG solution or the identical-looking placebo solution three times a day, AFTER THE NURSE MECHANICALLY BRUSHED THE TEETH. What the real lesson may be is that BRUSHING AND RINSING THREE TIMES A DAY is what may have lowered the respiratory infections for both groups – regardless of the use of CHG.

Kenneth Shay (2014) noted that research on chlorhexidine has been “so-so”. As noted above, the oral care procedures in research vary greatly. DeRiso’s study (1996) noted only that “all patients also received the standard oral care of the ICU.” What is the standard? This lack of consistency in an oral care protocol has impeded the implementation of best practice. However, Shay summarized that most interventions have reduced pneumonia by 25-50%. Studies have also showed reduction in bacteria counts, length of stay, and febrile days.

Steps for using Chlorhexidine Gluconate (CHG):

1. Ultimately, use as directed by your doctor and/or dentist.
2. Use after breakfast and before bedtime.
3. Brush the patient’s teeth first, removing all debris. If patient has dentures, remove and brush them.
4. Pour prescribed dose of 0.12% CHG into a medicine cup. If using Peridex* brand, then the usual dosage is 15ml (per the company 3M, 2009).
5. Soak swab in CHG solution. Swab along teeth, roof of mouth, tongue, and gum line using small circular motions for at least 30 seconds.

• • • If patient is alert and able, have him/her swish for 30 seconds and spit.
    • Do Not Swallow the solution.
    • Apply solution when patient is in an upright position.
    • Help prevent spillage into throat by using pillows or towel rolls behind head to tuck the chin down.

4. Suction to remove excess CHG solution from mouth.
5. Do not rinse mouth with water after application.
6. Do not eat or drink right after application.

*NOTE: Unfortunately, the Peridex (Chlorhexidine Gluconate 0.12%) Oral Rinse has 11.6% alcohol. We are always advising to avoid mouthwashes with alcohol to avoid irritation and dry mouth. Therefore, this may not be appropriate for patients at risk for mucositis or who have mouth discomfort after chemotherapy and radiation.

4. Cetylpyridunium Chloride (CPC):

Cetylpyridunium Chloride is another broad-spectrum antimicrobial, inactivating oral bacteria. It may be an alternative to Chlorhexidine in cases of sensitivity to Chlorhexidine. CPC is also effective on Candida species.

Latimer, et al (2014) compared 0.075% Cetylpyridunium Chloride mouth rinse with a control formula. The CPC showed a significantly greater reduction of oral bacteria and inactivation of biofilm (Actinomyces viscosus, Streptococcus mutans, Fusobacterium nucleatum) with 30 seconds of exposure. There was no difference in fluoridated versus non-fluoridated CPC. It also inhibited biofilm formation on pretreated discs (biofilm was grown on discs with human saliva as an inoculum).

Note: The SAGE product of 0.05% CPC listed below does not contain alcohol.

5. SAGE Products: Oral Cleansing and Suctioning Systems and Toothette Oral Care

I received no financial reward for discussing SAGE products here. They used to be the only company providing products to comprehensively prevent not only Ventilator Acquired Pneumonia, but also Hospital Acquired Pneumonia (aka, HCAP – Health Care Associated Pneumonia).

Now there is also the company MEDLINE, who provide 24 hour kits with instructions to perform the oral care every 4 hours (the box is labeled Q4 / 24 hour). They have kits also for individuals who are not on the ventilator, as well as kits designed for kids’ mouths.

SAGE Products (now part of Stryker) created simple, step-by-step intervention packets that can be used across the hospital, nursing/rehabilitation facility, or in the home. (See Oral Hygiene Brochure.) The Q-Care 24 hour Suction Systems contain suction toothbrushes and Chlorhexidine rinses, which are perfect for the ICU and ventilated patients. The Q-Care Continue Care and Suction Systems provide suction toothbrushes with mouthwash and oral moisturizers, which are sufficient for dependent patients on the medical and surgical floors. A hospital could at least purchase the single-use suction toothbrush packets (order#6572), which cost less than $2.00 each, but may save the hospital well over $50,000 for each Hospital Acquired Pneumonia in terms of costs, length of stay and Medicare penalties!

SAGE has a new program called Non-Ventilator Hospital Acquired Pneumonia Toolkit. Click Here for the SAGE Oral Hygiene Programs for Non-Ventilated Patients. This Patient Education Card is in Spanish and English.

SAGE oral care kits may include:

• Suction toothbrush. The single most important item to have when cleaning a patient’s mouth who cannot brush his/her own teeth and tongue.
• Suction swab. Helps remove debris from mouth and gums.
• Yankauer suctions with retractable sleeves to keep Yankauer clean/protected.
• Non-suction, non-treated swabs to apply solutions and moisturizers.
• Sodium Bicarbonate (baking soda) is embedded in the toothbrushes and swabs. This may help combat the acidity.
• Peridex (Chlorhexidine Gluconate 0.12%) oral rinse. Provides antimicrobial activity during oral rinsing. Indicated for treatment of gingivitis. Needs prescription and documentation in medical record.
• Perox-A-Mint solution: 1.5% hydrogen peroxide to mechanically clean and debride.
• Antiseptic Oral Rinse: 0.05% Cetylpyridinium Chloride (CPC) reduces the chance of infection by reducing bacteria.
• Antiplaque Solution: 0.05% Cetylpyridinium Chloride (CPC) also helps remove plaque.
• Standard Alcohol-free mouthwash
• Mouth Moisturizer: water-based with Vitamin E and coconut oil can be applied, but not at the same time as the Chlorhexidine oral rinse.

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— Special section on mucositis and oral pain–

How to provide oral care for patients with mucositis and oral pain:

Particularly patients recovering from head/neck cancer, who have received chemotherapy and radiation, have pain and discomfort in the oral cavity. I think some of my patients would say that is a gross understatement. It is hard to clean the mouth when in so much pain. However, it can become a vicious cycle. Poor oral health can be a causal factor in developing mucositis, causing even more pain. Mucositis may also be due to a low WBC (white blood cell) count and the necrotic and inflammatory effects of radiation. It can occur independent of fungal infections, like candida (thrush), but thrush may exacerbate the mucositis. Mucositis may not resolve until the absolute neutrophil count becomes >500 cell/ l.

What can a patient do if even a very soft toothbrush make’s them cringe? Ransier et al (1995) did find that a 0.2% chlorhexidine-saturated foam swab was as effective as a toothbrush in removing plaque and gingivitis. They reiterated that a foam swab alone was useless.

However, what about the potential alcohol content of a chlorhexidine solution?

I recall when one of my patients (after his chemo/radiation) drank a little red wine. He said the alcohol caused him to hit the ceiling. It also seemed to set-back his oral healing process. Any mouthwash that contains alcohol may not be tolerated.

Saltwater and baking soda mouth rinses can be used to clean and prevent mucositis.

Think alkaline!

Here are some solutions to discuss with your medical team:

1. 1 teaspoon of baking soda dissolved in 8 ounces of water.
2. ½ tsp of salt, 2 tablespoons of baking soda dissolved in 4 cups of water.
3. Sea minerals: Dr Wellington Espirito Santo Cavalcanti, DMD, oral surgeon, (personal communication, August, 2014) shared promising research that they are performing at the State Institute of Hematology-Arthur Siqueira Cavalcanti of Rio de Janeiro. They gave 25 study patients with Leukemia (Acute Mieloide Leukemia – AML and Acute Lymphoid Leukemia – ALL) tablets of a concentration of sea minerals of organic origin (one 500mg tablet, 2 times a day), keeping the pH of the saliva at 7.0-7.5. The 25 patients in the study had no complications, and only 6 had a “light mucositis,” which was “easily controlled.” Even 3 of the neutropenic patients were free from infection. Whereas, 30 controls with Leukemia  did not take the food supplement, and their saliva was more acidic at 6.0-6.5, causing increased mucositis. He concluded that the sea minerals kept the pH alkaline and the oral microbiota unchanged, which prevented the growth of opportunist microorganisms.

Talk to your doctor (especially your ENT), your dentist, and your pharmacist.

Medications your doctor may prescribe for pain relief and/or healing:

1. OraMagic Plus Mouthwash – pain relief (benzocaine is a topical anesthetic)
2. “Magic Mouthwash” compound solutions – created by MD and pharmacist with a prescription.

Per the Mayo Clinic, a Magic Mouthwash compound MAY contain:

• Antibiotic if bacteria around sores
• Antihistamine to reduce discomfort (Benadryl)
• Topical anesthetic to reduce pain (Lidocaine)
• Anti-fungal if fungal growth suspected (Nystatin)
• Corticosteroid to treat inflammation
• Antacid to enhance the mouth coating of the other ingredients (Maalox)

Caution regarding these solutions:

• Your doctor will create the formula right for you.
• The pharmacist will give directions on how to swish in the mouth (i.e., to swish for 1-2 minutes and swallow or spit out the solution).
• FOR MAXIMUM EFFECT OF THE SOLUTION, DO NOT EAT RIGHT AFTER TAKING THE SOLUTION, especially if there is a numbing agent. You can spot-treat the sores directly.
• If you swallow it, keep in mind there will be more side effects of the medications (i.e., Benadryl causes drowsiness).

Other final tips:

• Avoid oil-based lip balms (i.e., those containing white petrolatum). They can promote the infection. They do not penetrate, moisturize or heal the tissues.
• Avoid SLS (Sodium Lauryl Sulfate) in toothpaste. Look for label to say SLS-Free Toothpaste.
• Avoid Alcohol-based mouthwashes to avoid drying out the mucosa and causing local irritation.
• Ask your doctor for an artificial saliva substitute spray or gel. There are many manufacturers.
• If Platelet count is <40,000, avoid flossing or vigorous debridement of the mouth due to risk for bleeding.

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Thank you for reading Part I,  Part II,  Part III, and this Part IV of Oral Hygiene and Aspiration Pneumonia Prevention!

I hope I have provided information to help create your own hospital oral hygiene policies.

Check out this pdf to provide staff in how to perform good oral care: Oral Care Procedures for Aspiration Pneumonia Prevention

References for Part IV of Oral Hygiene and Aspiration Pneumonia Prevention:

Addems, A., Epstein, J.B., Damji, S. & Spinelli, J. (1992). The lack of efficacy of a foam brush in maintaining gingival health: A controlled study. Special Care Dentistry, 12, 103-106.

Bellissimo-Rodrigues, F. et al (2009). Effectiveness of oral rinse with chlorhexidine in preventing nosocomial respiratory tract infections amoung intensive care unit patients. Infection Control and Hospital Epidemiology, 30 (10), 952-958.

Cason, C.L., Tyner, T., Saunders, S. & Broome, L. (2007). Nurses’ implementation of guidelines for ventilator-associated pneumonia from the Centers for Disease Control and Prevention. American Journal of Critical Care, 16, 28-37.

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 nonprophylactic systemic antibiotic use in patients undergoing heart surgery. Chest, 109 (6).

Latimer, J., Munday, J.L., Buzza, K.M., Sreenivasan, P.K. & McBain, A.J. (2014, June). Antibacterial efficacy of mouthrinses containing Cetylpyridinium Chloride. IADR General Session. Cape Town, South Africa.

NICHE (2009). Geriatric Resource Nurse Core Curriculum [Power Point Presentation]. Hartford Institute for Geriatric Nursing. New York University College of Nursing, New York, New York.

Ransier, A., Epstein, J.B., Lunn, R. & Spinelli, J. (1995). A combined analysis of a toothbrush, foam brush, and a chlorhexidine-soaked foam brush in maintaining oral hygiene. Cancer Nursing, 18 (5), 393-396.

Shay, K. (2014, April). Dental perspectives on aspiration pneumonia causes and management. Health Care and Business Institute. Lecture conducted from ASHA conference, Las Vegas, NV.

Sole, M.L., Byers, J.F., Ludy, J.E., Zhang, Y., Banta, C.M. & Brummel, K. (2003). A multi-site survey of suctioning techniques and airway management practices. American Journal of Critical Care, 12, 220-230.

Tombes, M.B. & Gallucci, B. (1993). The effects of hydrogen peroxide rinses on the normal oral mucosa. Nursing Research, 42 (6), 332-337.

Wellington Espirito Santo Cavalcanti, W.E.S et al (September, 2013). The control of alkaline pH of the saliva through a concentration of sea minerals of organic origin in patients suffering from Acute Myeloid Leukemia and Acute Lymphoid undergoing chemotherapy: Pilot study. Jokull Journal, 63 (9).

5 Million Lives Campaign. Getting Started Kit: Preventing Ventilator-Associated Pneumonia How-to Guide. Cambridge, MA. Institute for Healthcare Improvement, 2010.