Oral Care to Reduce Mouth and Throat Infections in Critically Ill Patients
Oral Care to Reduce Mouth and Throat Infections in Critically Ill Patients
This study will evaluate whether a program of systematic oral care can help prevent
 hospital-acquired respiratory infections in patients in intensive care units. Such infections
 occur five times more often in critically ill patients compared with patients in general
 hospital wards and result in longer hospital stays and an increased risk of death. The rate
 of respiratory infection among critically ill patients correlates strongly with the presence
 of disease-causing bacteria in the mucosal areas of the mouth, gums, and teeth, indicating
 that assiduous oral care is especially important in this patient population. This study will
 compare a program of meticulous oral care using oral assessments taught by a dentist and
 dental hygienist with the standard care typically given in intensive care units.

 Critically ill patients 18 years of age and older who are hospitalized in an intensive care
 unit for 3 or more days and whose oral hygiene is dependent on hospital care providers may be
 eligible for this study. Patients will be recruited from intensive care units at four
 Washington, D.C., area hospitals - Suburban Hospital, Washington Hospital Center, Inova
 Fairfax Hospital, and Winchester Medical Center.

 Participants will have their lips, mouth, gums, teeth, and saliva examined several times a
 day to determine their optimum oral care. They will receive standard care, such as flossing,
 brushing, rinsing with a mouthwash, and possibly use of an antiseptic spray that prevents
 bacteria from clinging to the teeth. Small samples of saliva (less than one-fourth of a
 teaspoon) and dental plaque will be collected the day the patient is admitted to the
 intensive care unit and again on days 3 and 5 of their stay in the unit. The saliva sample is
 collected with a small suction tube placed in the corner of the mouth; the plaque specimen is
 collected by gliding a tiny piece of paper over the surface of a front tooth. The samples
 will be examined for any bacteria not normally found in saliva.
Critically ill patients, especially those that require endotracheal intubation, have the
 greatest risk of any hospitalized patient for acquiring nosocomial pneumonia. Nosocomial
 pneumonia, in this population, produces a substantial increase of mortality and morbidity.
 The literature suggests the causative pathway is aspiration of oropharyngeal pathogens found
 in dental plaque. The build-up of dental plaque has been significantly associated with
 subsequent nosocomial respiratory infections. Thus, prevention of pathogens colonization in
 the oropharyngeal cavity could be an effective infection control measure.

 Dental plaque once it reaches a critical thickness, acts as a reservoir for both aerobic and
 anaerobic pathogens. Failure to remove plaque begins a complex cascade of biological activity
 by which pathogens adhere to mucosal and tooth surfaces and pathogen overgrowth ensues.
 Additionally, neglected or insufficient mouth care is the foremost predisposing factor to
 oral conditions such as gingivitis, mucositis, and stomatitis which supply additional ports
 of entry for pathogens.

 There are only a handful of studies that compare the frequency and type of oral hygiene
 required to prevent or decrease oropharyngeal colonization. A recent pilot study, 01-CC-0207,
 compared oral care provision in two intensive care units (ICU) in the Clinical Center. The
 test ICU offered meticulous oral hygiene through a system of regular oral assessments taught
 by a dentist and dental hygienist. The score from the assessment determined the type and
 frequency of oral care. The control ICU gave standard care typical of the ICU community.
 Plaque and saliva assays were collected from the enrolled patients. Significantly lower Beck
 scores and lower colony forming organisms in the specimens was achieved in the test ICU on
 day 3, p less than 0.03 and p less than 0.001 respectively.

 This protocol will expand the pilot into a prospective randomized assigned trial conducted at
 four hospitals in the Washington D.C. area. These hospitals have ICUs more representative of
 ICU's nation-wide. This study will test the effectiveness of a comprehensive and systematic
 oral care program to reduce the oral assessment scores, mucosal plaque scores, and the amount
 of pathogen inoculum present in the saliva and plaque. Intubated and non-intubated patients
 will be compared as well as meticulous care with or without the addition of the oral
 antiseptic, chlorhexidine. Consistency of practice performance will also be evaluated when
 nursing staff has dentist/hygienist instruction and monitoring versus the traditional nurse
 instruction.
-  INCLUSION CRITERIA:

 -  Male or female adult ICU patients whose oral hygiene is dependent upon hospital care
 providers.

 -  Expected length of ICU stay is greater than or equal to 3 days.

 -  Any gender and ethnicity.

 EXCLUSION CRITERIA:

 -  Individuals and or responsible family members who are unable to provide consent.

 -  Any individual under the age of 18 years.

 -  Any individual whose expected admission is less than 3 days.

 -  Adult ICU patients whose admission CPIS score is greater than 6.

 -  Individuals who are able to provide own oral care.

 -  Individuals who have oral surgery that requires specialized oral care and assessment.

 -  Edentulous patients.

 -  Any patient with a prosthetic heart valve or who routinely takes prophylactic
 antibiotics before routine dental procedures.

 -  Any patient with a known allergy to chlorhexidine.