The Effect of Brush Motion and Rinsing When Manually Cleaning Cannulated Medical Devices.

Cleaning cannulated medical devices can be challenging for perioperative and sterile processing department personnel. We performed a laboratory experimental study to evaluate differences in cleaning effectiveness using either a back-and-forth or helical spinning brushing motion and the effect of rinsing the bristles at each reintroduction of the brush in the lumen. We also tested the lumen cleanliness after high-pressure water cleansing without brushing. We inspected the devices to determine whether visible soil remained, and we measured the amount of residual organic matter using adenosine triphosphate testing to determine cleaning method effectiveness. The results showed that rinsing the brush during cleaning decreased the amount of organic material that remained in the lumen. A helical spinning motion with brush rinsing at each reintroduction of the brush may be more effective than back-and-forth brushing with rinsing, but additional testing with a larger sample size is required to determine whether this result is replicable.

A randomized clinical trial of the anti-caries efficacy of 5,000 compared to 1,450 ppm fluoridated toothpaste on root caries lesions in elderly disabled nursing home residents.

Root caries is prevalent in elderly disabled nursing home residents in Denmark. This study aimed to compare the effectiveness of tooth brushing with 5,000 versus 1,450 ppm of fluoridated toothpaste (F-toothpaste) for controlling root caries in nursing home residents. The duration of the study was 8 months. Elderly disabled residents (n = 176) in 6 nursing homes in the Copenhagen area consented to take part in the study. They were randomly assigned to use one of the two toothpastes. Both groups had their teeth brushed twice a day by the nursing staff. A total of 125 residents completed the study. Baseline and follow-up clinical examinations were performed by one calibrated examiner. Texture, contour, location and colour of root caries lesions were used to evaluate lesion activity. No differences (p values >0.16) were noted in the baseline examination with regards to age, mouth dryness, wearing of partial or full dentures in one of the jaws, occurrence of plaque and active (2.61 vs. 2.67; SD, 1.7 vs.1.8) or arrested lesions (0.62 vs. 0.63; SD, 1.7 vs. 1.7) between the 5,000 and the 1,450 ppm fluoride groups, respectively. Mean numbers of active root caries lesions at the follow-up examination were 1.05 (2.76) versus 2.55 (1.91) and mean numbers of arrested caries lesions were 2.13 (1.68) versus 0.61 (1.76) in the 5,000 and the 1,450 ppm fluoride groups, respectively (p < 0.001). To conclude, 5,000 ppm F-toothpaste is significantly more effective for controlling root caries lesion progression and promoting remineralization compared to 1,450 ppm F-toothpaste.

Effects of a standard versus comprehensive oral care protocol among intubated neuroscience ICU patients: results of a randomized controlled trial.

The purpose of the study was to compare changes in oral health during intubation until 48 hours after extubation in neuroscience intensive care unit (ICU) patients enrolled in a standard or a comprehensive oral care protocol. The effects of manual toothbrushing (standard group, n = 31) were compared with those of tongue scraping, electric toothbrushing, and moisturizing (comprehensive group, n = 25) in intubated patients in a neuroscience ICU in a 2-year randomized clinical trial. Oral health was evaluated based on the Oral Assessment Guide (OAG) on enrollment, the day of extubation, and 48 hours after extubation. There were no significant differences in the frequency of the oral care protocol. Protocol compliance exceeded 91% in both groups. The total OAG score and all eight categories significantly deteriorated (Friedman test, p < .001, Bonferroni corrected) in the standard oral care group and did not return to baseline after extubation. Large effect sizes were present at all three points in this group. The total OAG score deteriorated during intubation within the comprehensive protocol group (Friedman test, p < .004) but returned to baseline status after extubation. In four categories, the ratings on tongue, mucous membranes, gingiva, and teeth did not deteriorate significantly over time. Published oral care protocols are substandard in promoting and maintaining oral health in intubated patients. A comprehensive oral care protocol, using a tongue scraper, an electrical toothbrush, and pharmacological moisturizers, was more effective for oral hygiene throughout intubation and after extubation than manual toothbrushing alone.

Efectividad de los cuidados orales en la prevención de la neumonía asociada a ventilación mecánica. Revisión sistemática y meta-análisis de ensayos clínicos aleatorios / Effectiveness of oral care in the prevention of ventilator-associated pneumonia. systematic review and meta-analysis of randomised clinical trials

Objetivo: Determinar la efectividad de los cuidados orales en la prevención de neumonía asociada a ventilación mecánica (NAVM). Método. Búsqueda en CINHAL, Cuiden Plus, Pub Med, EMBASE, ENFISPO, Cochrane, Cuiden, DARE, EBE, JBI, y búsqueda inversa, desde el comienzo de indexación de cada base hasta el 3-5-2010. No se ha restringido el idioma, edad, sexo ni patología de base. Se han incluido ECA que comparan los cuidados orales y se determina su efectividad en la prevención de NAVM. Se han analizado diferentes intervenciones para determinar cuál es más efectiva y protectora. Se ha utilizado Epidat 3.1 para síntesis de datos. Se han revisado 858 artículos, de ellos solo 14 cumplían los criterios de inclusión. Resultados. Bajo modelo de efectos aleatorios se ha determinado resultados estadísticamente significativos a favor de la clorhexidina como factor protector frente a NAVM RR=0,7065; IC 95% [0,5568-0,8963]. La aplicación de clorhexidina 0,12% dos veces al día RR=0,69; IC 95% [0,53-0,91] y clorhexidina 2% cuatro veces al día RR=0,53, IC 95% [0,31-0,90] aportan resultados estadísticamente significativos. Clorhexidina 0,12% y 0,2% tres veces al día y cepillado de dientes no aportan resultados estadísticamente significativos. Conclusiones. La aplicación de clorhexidina en los cuidados orales es un factor protector frente a la NAVM. El cepillado de dientes no previene la NAVM: serían necesarios más estudios ECA con esta intervención (AU)

Objective: To determine the effectiveness of oral care in preventing pneumonia associated with mechanical ventilation (VAP). Method. A search was made for randomised clinical trials (RCTs) in CINAHL, Cuiden Plus, Pub Med, EMBASE, ENFISPO, Cochrane, Cuiden, DARE, EBE, JBI, and reverse lookup from the beginning of indexing of each database up to 3 May 2010. There were no restrictions on language, age, sex or underlying disease. RCTs that compared oral care and determined their effectiveness in preventing VAP were included. The different interventions were analysed to determine the most effective and protective. Epidat 3.1 was used for analysing the data. Out of a total of 858 articles reviewed, only 14 met the inclusion criteria. Results. Using a random effects model statistically significant results were found in favour of chlorhexidine as a protective factor against VAP (RR=0.7065, 95% CI: 0.5568-0.8963). The application of 0.12% chlorhexidine twice a day gave an RR: 0.69, 95% CI: 0.53 - 0.91 and 0.2% chlorhexidine four times daily: (RR=0.53, 95% CI: 0.31 to 0.90), being statistically significant. The application of 0.12% and 0.2% chlorhexidine three times a day and brushing did not give statistically significant results. Conclusions. The use of chlorhexidine in oral care is a protective factor against VAP. Tooth brushing did not prevent VAP. More RCTs using this intervention are needed to confirm these results (AU)

Evidence to support tooth brushing in critically ill patients.

Tooth brushing in critically ill patients has been advocated by many as a standard of care despite the limited evidence to support this practice. Attention has been focused on oral care as the evidence accumulates to support an association between the bacteria in the oral microbiome and those respiratory pathogens that cause pneumonia. It is plausible to assume that respiratory pathogens originating in the oral cavity are aspirated into the lungs, causing infection. A recent study of the effects of a powered toothbrush on the incidence of ventilator-associated pneumonia was stopped early because of a lack of effect in the treatment group. This review summarizes the evidence that supports the effectiveness of tooth brushing in critically ill adults and children receiving mechanical ventilation. Possible reasons for the lack of benefit of tooth brushing demonstrated in clinical trials are discussed. Recommendations for future trials in critically ill patients are suggested. With increased emphasis being placed on oral care, the evidence that supports this intervention must be evaluated carefully.

Electric versus manual tooth brushing among neuroscience ICU patients: is it safe?

BACKGROUND: Poor oral hygiene has been associated with ventilator-acquired pneumonia. Yet providing oral care for intubated patients is problematic. Furthermore, concerns that oral care could raise intracranial pressure (ICP) may cause nurses to use foam swabs to provide oral hygiene rather than tooth brushing as recommended by the American Association of Critical-Care Nurses. Evidence is needed to support the safety of toothbrushing during oral care. We therefore evaluated ICP and cerebral perfusion pressure (CPP) during oral care with a manual or electric toothbrush in intubated patients in a neuroscience intensive care unit (ICU). METHODS: As part of a larger 2-year, prospective, randomized clinical trial, 47 adult neuroscience ICU patients with an ICP monitor received oral care with a manual or electric toothbrush. ICP and CPP were recorded before, during, and after oral care over the first 72 h of admission. RESULTS: Groups did not differ significantly in age, gender, or severity of injury. Of 807 ICP and CPP measurements obtained before, during, and after oral care, there were no significant differences in ICP (P = 0.72) or CPP (P = 0.68) between toothbrush methods. Analysis of pooled data from both groups revealed a significant difference across the three time points (Wilks' lambda, 12.56; P < 0.001; partial η(2), 0.36). ICP increased significantly (mean difference, 1.7 mm Hg) from before to during oral care (P = 0.001) and decreased significantly (mean difference, 2.1 mm Hg) from during to after oral care (P < 0.001). CONCLUSIONS: In the absence of preexisting intracranial hypertension during oral care, tooth brushing, regardless of method, was safely performed in intubated neuroscience ICU patients.

Hydration and nosocomial pneumonia: killing two birds with one stone (a toothbrush).

Clear and compelling evidence exists in the literature to suggest that nosocomial pneumonia is linked to poor oral care. In nursing homes and intensive care units, practicing good oral care has been demonstrated to reduce the risk of aspiration pneumonia (Furr, Binkley, McCurren, & Carrico, 2004). In an oral care program implemented in a 29-bed rehabilitation unit, lung status was improved in 77% of patients who were admitted with aspiration pneumonia. Key components of the forces of magnetism (American Nurses Credentialing Center, n.d.) were used to implement the program, including autonomy and interdisciplinary relationships. The rehabilitation unit also applied the theory proposed by Higgins and Howell, which promotes using champions to make important process changes (1990). This article reviews the steps one rehabilitation unit took to implement an oral care plan.

[Daily living activities and oral condition among care facility residents with severe intellectual disabilities. Comparative analyses between residents receiving tooth-brushing assistance and those not receiving tooth-brushing assistance].

OBJECTIVES: To clarify 1) differences in daily living activities and oral condition among care facility residents with severe intellectual disabilities and 2) chronological changes in daily living activities and oral condition for residents receiving tooth-brushing assistance and those never receiving tooth-brushing assistance. METHODS: Subjects were 44 residents at a care facility for individuals with severe intellectual disabilities, who underwent dental screening in July 1994 and October 2003. At each time point, daily living activities, behavior during oral health guidance, behavior during dental health screening and oral condition were compared between residents receiving tooth-brushing assistance (assistance group) and those not receiving tooth-brushing assistance (independent group). Furthermore, chronological changes were analyzed for residents requiring assistance at both screenings, those requiring assistance only at the second screening, and those not requiring assistance at either screening. RESULTS: 1) In the assistance group, 100% and 36.4% of residents were unable to brush their teeth independently in 1994 and 2003, respectively. Significant differences between the assistance and independent groups were observed in all items of behavior during dental health screening in 1994, but not in 2003. No significant intergroup differences in oral condition were observed in 1994, but differences were seen in 2003; when compared to the assistance group, the number of lost teeth was significantly higher in the independent group, while the number of remaining teeth was lower. 2) Regarding changes over the nine-year period, a significantly greater proportion of residents not requiring assistance at either screening and those requiring assistance only at the second screening finally required assistance in bathing. As for oral condition, no significant changes in healthy teeth were observed in residents requiring assistance at both screening time points, while significant increases in dental caries and filled teeth and a significant decrease in the number of healthy teeth were observed in residents requiring assistance only at the second screening and those not requiring assistance at either screening. CONCLUSIONS: Over the nine-year period, the subjects of tooth-brushing assistance changed, and assistance was given to those able to brush their teeth independently in addition to those unable to brush their teeth independently. The number of healthy teeth did not change in residents receiving tooth-brushing assistance during this period, but in residents never receiving tooth-brushing assistance, decrease was noted. Therefore, even for individuals able to brush their teeth independently, some form of tooth-brushing assistance is needed to sufficiently prevent oral diseases.

A survey of the oral care practices of intensive care nurses.

BACKGROUND: Intensive care unit (ICU) patients have complex oral care needs. Inadequate oral care may predispose ICU patients to nosocomial infections. Recent initiatives have sought to improve the quality and evidence base of ICU oral care provision. OBJECTIVES: To describe the current priority given to oral care, the knowledge and practice of oral needs assessment and oral care methods, and adherence to the local ICU oral care protocol of ICU nurses working in one hospital. METHOD: Self-administered questionnaire survey of all nurses working in adult ICU ( n = 160 ). RESULTS: Replies were received from 103 (response rate 64.5%). On average, oral care was given a similar priority to other aspects of personal care. 13.5% nurses rated oral care as a low priority. Whilst 98% nurses routinely performed an oral needs assessment, only 26% used a written assessment tool. Toothbrushes were used at least once a day by 85.5% nurses and chlorhexidine products were routinely used by 50.5% nurses. The oral care practices of most nurses matched the local ICU protocol. 23.5% nurses had received no training in oral care and 58% nurses requested initial/further training. CONCLUSIONS: Most oral care methods were appropriate, based on the available evidence. A small minority of nurses gave oral care a low priority and were not using evidence-based oral care methods recommended in the local ICU protocol. Encouraging the general use of oral needs assessment tools is a priority, and further oral care training is required.

A comparison of three oral care products commonly used in practice.

This project compared the efficacy, patient satisfaction, and cost of three commonly used oral care products: lemon glycerin swabs, Moi-Stir swabs, and toothettes (pink sponge applicators) and water. Hospitalized adults who were either required to receive nothing by mouth or who required oxygen were asked to participate in the project. Once enrolled, the patients were randomly assigned to one of the three oral care groups. Oral assessments were performed daily, and perceptions of oral comfort were solicited from alert patients. Although the sample size was not large enough to reach statistical significance, a few trends were noted. First, the patients' oral condition generally worsened during the first 3 days but then improved between Days 4 and 5. Moi-Stir performed better than either lemon glycerin or toothettes and water, as evidenced by lower Day 4-5 scores. Patients generally liked the swab to which they were assigned.

A comparison of the ability of foam swabs and toothbrushes to remove dental plaque: implications for nursing practice.

This study aimed to assess the impact which the use of a toothbrush and the use of foam swabs had on the removal of dental plaque over a 6-day period. Three experiments were completed and duplicated using the author's mouth and one of these experiments was completed a third time on a volunteer's mouth. A plaque scoring system which quantified the amount of plaque on teeth in areas adjacent to periodontal tissue, and therefore capable of initiating inflammation, was used after plaque had been disclosed. Plaque at the gum/tooth margin (gingival crevice plaque) and plaque between teeth (approximal plaque) was measured. At the end of each 6-day period, which commenced with all tooth surfaces clean, the ability of the toothbrush to remove plaque was consistently better than that of swabs, and usually achieved complete visible plaque removal from all sites. In contrast, plaque remained in all sites which had been cleaned using foam swabs (after using a 'swabbing' or 'scrubbing' technique). However, it was possible to remove plaque from a number of gingival crevice sites with a swab when a varied 'any technique' was used on the visible disclosed plaque. The plaque in all approximal sites still remained after this technique. An experiment to measure the effect of using foam swabs on plaque which had been allowed to accumulate over a 6 day period produced similar results. The results from this study suggest that the success of a toothbrush in removing plaque is affected by user technique (total visible plaque removal was not achievable), and that foam swabs are not able to remove plaque from some 'sheltered' areas of teeth (total visible plaque removal was not achievable). The implications of these findings to nursing practice are discussed.

Oral hygiene care levels in Iowa intermediate care facilities.

This study was undertaken to improve understanding of current oral hygiene care practices in intermediate care facilities. Questionnaires were sent to directors of nursing of all licensed intermediate care facilities in Iowa. Results show that an estimated 57% of residents needed direct oral hygiene assistance. In all intermediate care facilities, the majority of direct oral hygiene care was provided by aides. Oral hygiene care was often not provided at an optimal level, and the main reasons reported for this lack of care were uncooperative residents (82%), lack of perceived need by aides (68%), and inadequate time/personnel (49%). Development and promotion of oral hygiene care programs in intermediate care facilities must take into consideration the realities and problems involved. Otherwise, efforts to introduce or implement new or improved care programs will fail.