Introduction
Poor oral hygiene is linked to antagonistic effects on the health of a critically injured or ill patient. However, taking good care of the oral cavity may be tedious for a patient admitted to an intensive care unit (ICU). Oral infections have the potential to cause other systemic diseases. ICU staffs and nurses are responsible for providing interventions that prevent oral infections and maintain oral health.
What Causes Oral Infections in an ICU Patient?
A critically ill patient in an ICU encounters many changes within the oral cavity. This can be due to the following reasons:
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Due to severe medical issues, proper oral hygiene measures may not be focussed in the case of a critically ill patient. Routine brushing of teeth, flossing, or tongue may not be possible in such cases. This may lead to the accumulation of plaque and calculus on the tooth surface. It can also lead to dental caries in the long run or other soft tissue infections or inflammation.
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The mouth of the patient may remain open due to orotracheal intubation. Prolonged exposure of the oral cavity to the external environment can cause dehydration of the oral tissues, dry mouth or xerostomia, soft tissue irritation, and halitosis or bad breath.
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The tongue may not be cleaned, leading to the development of a coating on the tongue surface. This can lead to halitosis.
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There are chances of infections like periodontitis (the inflammation of the periodontium or the tooth-supporting structures), gingivitis (gingival inflammation), and may outbreak, leading to pneumonia.
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Immunocompromised patients may get predisposed to conditions like oral candidiasis (an oral cavity infection caused by the fungus Candida albicans) and herpes simplex infections.
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Ventilated patients in an ICU may be subjected to suctioning devices, mouth props, and endotracheal tubes. This may be installed through the oral cavity and can lead to injuries. Oral injuries may get advanced to ulcers or infections.
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In addition, underlying systemic or metabolic conditions like diabetes may get worsened in case of critical illness and causes severe oral problems.
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Certain medications can lead to dry mouth or xerostomia, oral infections, dental caries, and halitosis.
What Are the Obstructions for Maintaining Oral Hygiene in Critical Patients?
The following are the barriers to maintaining oral hygiene in patients admitted to an intensive care unit:
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ICU contains less equipment that keeps the oral cavity clean and hygienic. ICU is meant to treat critical conditions, and the staff usually fails to restock oral hygiene equipment.
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Inability to perform self-oral hygiene measures due to the critical limitations the patients are facing.
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Less focus is given by the ICU staff in providing oral care due to other severe health issues requiring emergency attention and treatment.
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Instruments and devices installed orally may act as mechanical obstructions to oral hygiene.
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Connecting mechanical tubes or devices leaves less space within the oral cavity, making it hard for the ICU staff to inspect and clean the mouth.
How Does Impaired Oral Health Cause Systemic Problems in an ICU Patient?
The oral cavity is the resort for a variety of microorganisms. These organisms may also appear on the biofilm smeared on the surface of the tooth and the tongue. If oral hygiene is not well-maintained, these organisms affect the structure and function of the oral tissues, leading to dental caries, gingivitis, periodontitis, and other conditions. If the decayed tooth is left untreated or unnoticed, it may lead to the subsequent death of the tooth, followed by pus and abscess formation, the affection of the underlying bone, and sinus. This can also lead to space infections that may spread to other adjoining body parts, leading to pain and other symptoms.
Diabetes and periodontitis are associated with each other. Periodontitis can lead to hyperglycemia (high blood glucose levels), causing the metabolic condition called diabetes. Diabetes can also lead to periodontitis. In critically ill patients, either mechanism may happen, leading to periodontitis and diabetes.
Adequate saliva production and salivary flow maintain the moisture within the oral cavity and prevent infections. Critical care may lead to a condition called xerostomia or dry mouth, characterized by decreased salivary production. This may aggravate the dental issues and oral cavity injuries caused by the devices used in a critically ill patient. Bacterial infections get severe in critical patients, leading to bacteremia (the presence of bacteria in the blood). Bacteremia, along with other inflammatory conditions, may lead to the formation of clots in the lumen of the blood vessels. This leads to a condition called atherosclerosis.
The oral cavity is one of the entry points of the body. The microorganisms get aspired towards the respiratory tract leading to pulmonary diseases like COPD (chronic obstructive pulmonary disease), bronchitis (inflammation of the bronchus), emphysema (destruction of the lung’s air sacs), and ventilator-associated pneumonia. The chances of getting respiratory illness are more in critical patients under ventilation.
How to Conduct an Oral Health Assessment in Critical Patients?
An oral health assessment should be conducted in critical patients to assess the existence of prior oral problems, study the progress of the existing oral infections, and observe the development of new oral issues. The intraoral examination should check for teeth, saliva, and soft tissue changes. During general assessment done to critical patients, oral assessment should also be conducted to prevent the advancement of oral issues. Beck oral assessment scale (BOAS) and Mucosal plaque score are proven tools that help to assess oral tissues.
How to Maintain Oral Health in Critically Ill Patients?
Oral health in critically ill patients can be improved or maintained by the following measures:
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Using oral antiseptic solutions will be helpful. These solutions usually contain chlorhexidine. It has a broad-spectrum antimicrobial activity and reduces plaque formation.
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Mechanical means of oral hygiene improvement includes tooth brushing. Tooth brushing can be combined with antiseptic solutions for better results. The toothbrush should be small-sized and with soft bristles. This can also be used in the case of edentulous patients.
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Non- antiseptics containing bicarbonates and saline can also be used. These can be used as rinses or swabs dipped in the solutions.
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Swabbing with foam can also be done if using a toothbrush gets tough.
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Dental decay can be prevented by topical fluoride application.
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Intermittent rinsing of the oral cavity with plain water will also be helpful.
Conclusion
Oral health is essential, as worse oral hygiene may lead to more complicated systemic conditions. Coaching ICU nurses in order to provide better oral health care to critical patients will be helpful. A dental surgeon can play a crucial role in the same intensive care unit. Most of the hospital management started appointing dentists in the ICUs to take care of the patient’s oral health.
