Oral Care to Reduce Mouth and Throat Infections in Critically Ill Patients

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.