Mouth Care in Patients Receiving Mechanical Ventilation: A Systematic Review
Context: Studies show that despite the role of mouth care in preventing ventilator-associated pneumonia, there is no high quality evidences for it. This study reviewed the literature related to mouth care in patients receiving mechanical ventilation.
Evidence Acquisition: PubMed, Ovide, Elsevier, ProQuest, IranMedex, SID, and Magiran databases were searched using key terms such as oral care, mouth care, critical care, and intensive care. Fifty-seven full-text articles in total were retrieved and included in the study.
Results: Totally, 15 review articles and 42 research articles were reviewed. Only 13 articles introduced or evaluated the validity of instruments or caring guidelines in the area of mouth care. Only one study discussed about designing and validating the psychometric properties of a mouth assessment scale. Most of the articles emphasized on brushing the teeth as the best method for mouth care, but there was no consensus on the frequency of washing and the best washing solution.
Conclusions: Despite the importance of mouth care, few original studies are conducted in this area and there is no approved clinical guideline for this procedure.
Keywords: Mouth; Respiration, Artificial; Nursing Care
Many studies have reported the association between inappropriate mouth care and pneumonia in patients receiving mechanical ventilation (1-3). The prevalence of ventilator-associated pneumonia (VAP) is 9-68% and the mortality rate is at least twice of those for other types of the disease (4-6). Studies showed that mouth care might be an effective intervention to reduce the occurrence of VAP (7-9); however, it was reported that neither patients receiving mechanical ventilation received appropriate mouth care nor this type of care was documented correctly (8, 10-15). The main reasons for inappropriate mouth care in patients receiving mechanical ventilations consisted of the lack of standard guidelines (1, 8, 16, 17), equipment and staff shortage (10, 18-20), and nurses’ lack of knowledge (2, 4, 6, 21-23). A recent study in Kerman, Iran, revealed that the nurses did not pay much attention to mouth care and considered it as a hard and unpleasant nursing care (13). Another study conducted in ICUs of three Iranian cities showed that in comparison with other caring measures, nurses ranked the mouth care as the seventh importance level. This study reported that only 29% of nurses were trained for mouth care (10). In another study, nurses reported that nursing training courses were ineffective in increasing their ability to provide appropriate mouth care (18). This study was conducted according to the importance of mouth care among patients receiving mechanical ventilation, its association with VAP, the importance of updating healthcare providers’ knowledge in this caring area, and for providing most recent evidences for mouth care among such patients. The aim of study was to review the most recent studies conducted in the area of mouth care among patients receiving mechanical ventilation hope to help nurses to make more effective decisions about mouth care in these patients.
2. Evidence Acquisition
We performed an internet-based literature review published between 2001 and 2012 to retrieve studies in the area of mouth care among patients under mechanical ventilation. English and Persian databases such as PubMed, Ovid, Elsevier, ProQuest, IranMedex, SID, and Magiran were searched using the following key terms: oral care, mouth care, critical care, and intensive care. All studies conducted on human subjects were included. We also searched the reference sections of retrieved articles to find other related studies. Excluding criteria included articles published in languages other than English or Persian, those studies that their complete contents were not retrievable, articles published in criticizing other studies, articles published as Letter-to-Editor, and studies conducted on healthy individuals or on patients not receiving mechanical ventilation. Totally, 93 papers were retrieved from which 57 papers were not repetitive (Figure 1).
Number of Papers Retrieved in Each Data Bank
Among 57 articles, 15 articles were review studies and 42 articles original research papers. In most of the review studies, the importance of mouth care and its association with VAP as well as advantages and disadvantages of materials and equipment used for routine mouth care were discussed (Table 1). Original research papers were provided in three areas:
The list of Review Studies Included in the Study
1) studies evaluating validity of instruments used for assessing mouth care,
2) descriptive studies investigating nurses’ performance for mouth care, and
3) studies investigating advantages and disadvantages of equipment and solutions used for providing mouth care (Table 2). Below, findings of the study were explained in five subsections including dental plaque and VAP, instruments designed for assessing mouth care, assessment of nurses’ routine practice in terms of patients’ mouth care, equipment used for mouth care, and materials and solutions used for mouth care.
The List of Original Research Articles Included in the Study
3.1. Dental Plaque and VAP
Plaque formation and its association with VAP was a prevalent topic in most of the retrieved review studies and few original research papers (4, 16, 20). It was reported that 48 hours after hospitalization, normal bacterial flora of oral cavity changed to opportunistic and pathogenic organisms (24). Moreover, dental plaques and caries grew secondary to fibronectin reduction at dental surface (4, 19, 24-26).
3.2. Instruments Designed for Assessing Mouth Care
Thirteen studies in total introduced or evaluated the validity of instruments or caring guidelines in the area of mouth care (1, 8, 9, 11, 21, 27-34). Although primary mouth assessment should be considered as an important part of ICU baseline assessment, among retrieved studies, only one article discussed about designing and validating the psychometric properties of mouth assessment scale (35). Additionally, the BRUSHED Assessment Model was discussed in five review studies (1, 20, 21, 27) while the Jenkins scale was referred to in two (27, 36). On the other hand, four studies noted that most of mouth assessment instruments are not valid and applicable for nurses (21, 27, 35, 36). These studies also emphasized on the importance of continuous mouth assessment and documentation at least every 12 hours (20, 21, 27, 28). Among retrieved studies, six studies investigated the effects of mouth care guidelines and reported a reduction of 61% to 100% in VAP incidence after implementation of the guidelines (8, 9, 28, 31-33). These guidelines consisted of procedures such as hand washing; preparing equipment and suction machine; brushing the teeth, gums, and tongue; mouth washing and suctioning (several times a day); application of humidity preserving materials; swabbing the teeth and mouth mucus membranes; and suctioning of the pharynx. Some of the guidelines were more extended and consisted of methods and frequencies of mouth assessment and ways of using the suctioning catheter (1, 21) while other guidelines were simple with merely the frequency of tooth-brushing (33). Most of the studies recommended tooth-brushing two to three times daily and moisturizing the lips and mouth mucus membranes every two to four hours (8, 21, 27).
3.3. Assessment of Nurses’ Routine Practice in Terms of Patients’ Mouth Care
Most studies highlighted nurses’ role in mouth care and 24 papers addressed this area directly. Four studies assessed the factors influencing on implementation of mouth care (18, 13, 10, 4) and nine studies investigated knowledge, attitude, and performance of nurses in regard to the implementation of this type of care (2, 3, 8, 12, 14, 17, 27, 35, 36). In nine studies, nurse-mediated health promotion strategies or effects of designing and implementing care guidelines on nurses’ performance were investigated (9, 13, 15, 21, 23, 29, 32, 34, 37). Several studies reported that nurses did not perceive the importance of mouth care (2, 10, 12, 22). Other studies noted that there were barriers in providing mouth care (3, 17). These barriers included nurses’ time limitation, staff shortage, heavy workload, poor supervision, poor teamwork, ineffective training, lack of standard guidelines, and unpleasant nature of the procedure (3, 18, 20). A study reported that the quality of mouth care was associated with receiving continuous education, nurses’ attitude toward the care, managers’ supervision, and having enough time, and it was not associated with the years of working experience and available equipment (18). Some studies reported that nurses did not document all aspects of the care [3, 5, 10]. Two studies from America (25) and Europe (3) conducted respectively in 102 and 57 ICUs reported that although nurses valued mouth care, their practice did not support their attitude.
3.4. Equipment Used for Mouth Care
Equipment used for mechanical washing of mouth included toothbrush, swab, and suction machine. A study reported that most ICU nurses limited their routine mouth care to a simple mouth and throat suctioning. In this study, the most prevalent procedure used for mouth care was simple mouth suctioning while tooth-brushing was implemented only in 16% of cases (10). Toothbrush is the most effective tool for removing bacterial colonies and dental plaques (4, 17, 21, 38) and is contraindicated only in patients with coagulation disorders (21). Compared with adult-sized toothbrushes, children-sized ones with a flexible stick are easier to use for providing mouth care in intubated patients (36). Eleven studies investigated the effects of tooth-brushing with a pharmacologic agent (4, 19, 28, 29, 31, 32, 37, 39-42). Moreover, four studies introduced or reported the results of using mouth care protocols and emphasized on the importance of using toothbrush (1, 8, 31, 33, 38). In four other studies, a list of necessary equipment for providing mouth care in patients receiving mechanical ventilation, and the importance of tooth brushing were discussed (4, 16, 21, 23). In seven studies the nurses’ mouth caring practice and its frequency were investigated (2, 3, 5, 10, 12, 13, 36). In a clinical trial, the fields compared routine mouth care practice with a once-every-eight-hour tooth-brushing practice method in patients hospitalized in ICU. After a six month period, the number of VAP episodes occurred in intervention and control groups was 0 and 4, respectively (28). However, Munro et al. reported that the occurrence of VAP in patients receiving only tooth-brushing care did not decrease significantly (24). Toothpaste was not used in any of the retrieved studies; instead, tooth brushing was performed using chlorhexidine or other mouth-washing solutions. Oral swab with cotton-like applicator is not a powerful device for removing dental plaques; however, it is useful for moisturizing oral cavity (4, 38). Several studies reported the use of swab for providing mouth care (38, 43-45). An Iranian study reported that oral swab with cotton-like applicator soaked in normal saline was used in more than 69% of cases to provide mouth care (10). Compared to swabbing, brushing for at least two times a day was more effective to prevent pneumonia occurrence (17).
3.5. Materials and Solutions Used for Mouth Care
Normal saline solution: incidence of VAP after application of normal saline in conjunction with chlorhexidine was investigated in only one study; the results showed no significant difference between the intervention and control groups (17, 45). Moreover, in seven studies the usability of normal saline solution or its application by nurses was addressed. However, normal saline solution bears drying effects and, therefore, is not recommended for mouth washing (1, 5, 16, 21, 27, 36). Tap and sterile water: only one study addressed the use of tap or sterile water in mouth care (11). Also, in seven papers tap water was referred to as an appropriate solution for moisturizing and cleaning the mouth, gums and teeth of patients receiving mechanical ventilation (4, 6, 16, 21, 36, 39, 46). Some studies noted that tap water was an appropriate environment for Pseudomonas growth; therefore, tap water containers should be small, sterile, and impenetrable with tightly-closed openings which the date of the first use should be written on containers (4, 16). Topical antibiotics: few studies addressed the use and efficacy of topical antibiotics in decontamination of oral cavity (4, 16, 24, 47). However, the use of topical antibiotics may increase the likelihood of bacterial resistance to antibiotics (24). Chlorhexidine: the effects of chlorhexidine in the prevention of bacterial colonization and VAP were addressed in 14 studies among which eight studies reported positive effects of the solution in the prevention of VAP (32, 34, 41, 48-52). However, six remaining studies reported that chlorhexidine, compared to placebo, did not produce significant difference in the incidence of VAP or bacterial colonization (19, 25, 31, 43, 46, 53). On the other hand, some studies confirmed the effectiveness of chlorhexidine in the reduction of respiratory infection in patients undergoing selective cardiac surgery (50, 52); however, the Center for Disease Control and Prevention (CDC) does not recommend routine use of the solution (19). Sodium bicarbonate solution: only one study investigated effects of sodium bicarbonate versus honey solution and reported that oral lesions were more prevalent in sodium bicarbonate group (54). Six studies referred to sodium bicarbonate as a mouthwash solution; however, inappropriate concentrations of the solution may lead to irritation and destruction of oral mucus membranes (4, 12, 16, 21, 24, 36). Hydrogen peroxide solution: we could retrieve only two original research papers in which diluted hydrogen peroxide for mouth care was discussed (11, 29). In addition, five studies referred to the diluted hydrogen peroxide as a traditional mouthwash solution (4, 16, 21, 23, 24). About 27% of nurses participated in one study also reported the use of the solution for mouth care (6). However, most of the retrieved studies warned about irritation and destruction of oral mucus membranes secondary to multiple use of hydrogen peroxide solution (2, 4, 8, 21). Povidone–iodine (Betadine): long-term use of Betadine was not recommended because of its absorption to blood through oral mucus membrane, change in normal bacterial flora of mouth, and likelihood of bacterial resistance (4, 16). Only three original studies investigated effects of the solution administration on mouth care (9, 30, 55). Moreover, three studies referred to Betadine as a mouthwash solution (1, 4, 16). Lemon juice and Glycerin: the use of lemon juice and glycerin and also their drying and irritating effects on mucus membranes and teeth were addressed in eight studies (2, 4, 6, 10, 21, 23, 28, 56). In one study (36) 2% and in another (6)19% of nurses reported the use of these solutions to provide mouth care.
Despite the importance of mouth care, enough evidence is not available about this care and its implementation method and frequency. There is a consensus among researchers on the association between inadequate mouth care and increased prevalence of VAP (4, 9, 24, 25, 47, 51, 57). However, there is no consensus on the manner, frequency, and appropriate solutions for mouth care in patients under mechanical ventilation. Lack of consensus may be resulted from the lack of well-designed studies. In our study, more than one fourth of the articles were review studies and one third of the research papers were descriptive studies according to knowledge, attitude, and performance of nurses. Several studies reported that tracheal tube, nasogastric tube, and tube-fixating tapes made oral cavity hard-to-access (4, 20, 36). Moreover, nurses were reluctant to perform mouth care worrying about tracheal tube displacement and/or aspiration (20, 36). Several European studies also reported the lack of a standard protocol for mouth care (5, 14, 35). On the other hand, studies showed that developing a caring protocol in conjunction with implementation of continuous education programs could improve quality of mouth care and decrease prevalence of VAP (31, 32, 37, 53). Adequate evidences for best practice protocols were partially provided in only 46% of retrieved studies. However, these studies not only failed to provide an agreed strategy to reach to a consensus on a caring guideline but also highlighted the lack of a standard improving protocol for mouth care of patients receiving mechanical ventilation. Also, lack of reliable evidence resulted in bewildering of nurses and affected their mouth care practices (17). Moreover, different findings reported by different clinical trials may be the result of practical biases, lack of precise monitoring and measuring of outcome variables, and inconsistent treatment methods (25). Therefore, to determine best practice protocols, still there is a need to conduct well-designed large-scale clinical trials. Despite the great importance of mouth care in patients receiving mechanical ventilation, there is no consensus on caring methods, , materials, and equipment . Therefore, investigators should consider mouth care in patients receiving mechanical ventilation as an important research area and attempt to provide high quality evidences for best practices. Finally, it is noteworthy that the number of studies with including criteria of this study was far beyond the number of retrieved studies; however, complete contents of those articles were not available to the authors.
The authors acknowledge the IT system in the faculty of nursing and midwifery.
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