Many thanks to my sponsor:

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1 Oral Care for the Medically Complex Patient: From Intensive Care to Long-term Care Michigan Dental Association Lansing MI April 25, 2015 Cindy Kleiman RDH, BS Oral Care Consultant and Speaker Many thanks to my sponsor: Ventilator Associated Pneumonia: The Perfect Storm A nosocomial pneumonia (infection of the lung) in a patient on a mechanical ventilator for 48 hours or longer 1

2 Dental Biofilm and VAP Normal flora convert to pathogenic within 48 hours of hospitalization, exacerbated by xerostomia Existing periodontal disease may increase risk 76% of VAP cases have lung culture displaying oral bacteria VAP in U.S. The Need for Cooperation 2 nd most common hospital-associated infection (#1 is urinary tract) Intubated patients are 6 to 21 times more at risk of contracting pneumonia than those not receiving ventilator support Increased mortality rates of 20-50% Increased hospital stays (an average of 10 additional days) and costs ($2 billion annually) Is oral hygiene safe among intubated patients? Dependent upon endotracheal tube for airway protection and management At high risk for micro-aspiration May be orally defensive May exhibit oral trauma or mutilation 2

3 AACN Practice Alert American Association of Critical Care Nurses Oral Care Protocol Written protocol for oral care Document frequency of oral care, differentiating between comprehensive oral care and moisturizing Brush teeth and tongue at least twice a day with a soft toothbrush Moisturize mucosa and lips No specific oral care products recommended Nursing: Professional Issues Long-standing nursing tradition of toothettes / foam swabs Patients in critical condition oral hygiene low priority No monitors / beeps No evidence-based oral care protocol Nursing schools not stressing oral care Oral care is low tech and difficult Oral Hygiene and Oral Assessments Outpatient oral hygiene and assessments Hygiene: Interproximal cleaning Tongue scraper Electric or quality manual toothbrush Oral rinse Assessments: Dentist/Hygienist Caries and periodontal Oral Cancer exam Radiographs Inpatient oral hygiene and assessments Hygiene: Swabs Pediatric, manual toothbrush Inconsistent mouthwashes, oral rinses Assessments: Nothing 3

4 Eilers Oral Assessment Guide (OAG) 7 Categories that are scored Swallow Lips Tongue Saliva Mucous membranes Gingiva Biofilm (plaque) Barrow Bedside Oral Examination (BOE) Scoring System: 1, 2, or 3 given in each category 1 Healthy (Score of 8 is optimum health) 2 Moderate involvement 3 Significant compromise (Worst score: 24) 4

5 Stroke (CVA) Sudden loss of brain function resulting from interference with the blood supply to a part of the brain 3 rd leading cause of death in the US Patient is frequently disabled by changes in motor skills, communication, and perception Stroke (CVA) Communication difficulties: Aphasia Inability to communicate verbally Dysarthria Speech difficulty caused by neuromuscular weakness Apraxia Inability to execute a purposeful movement, although no muscle or nerve injury occurred Lability Inability to control emotions Oral Complications of CVA Medications Aspirin or other anticoagulants - bleeding Antihypertensive - xerostomia Anticonvulsives - hyperplasia 5

6 Facial Muscle Weakness With Associated Sensory Loss Increased Food Pocketing Decay Periodontal Disease Clinical Modifications No routine care for 6 months Be sure to take blood pressure Do not lean on affected arm Speak directly to patient in normal voice May need to use yes or no questions Clinical Modifications Use straw for rinsing Caution used with ultrasonic or handpiece water Standard treatment is appropriate 6

7 Oral Hygiene Modifications Have patient observe areas of mouth that feel numb Difficulty in using opposite hand for oral hygiene Evaluation of oral care products Denture Suction Cup Brushes Can be purchased thru medical supply companies The Wright Stuff Inc 7

8 Tube Fed/TBI Patients Compromised ability to eat or drink due to lack of gag reflex At high risk for aspiration Orally defensive Grind teeth Self mutilation Xerostomia Tube Fed/T.B.I. Patients Very dry lips Coated tongue Decreased decay Increased calculus, occurs on occlusal surfaces Malodor Oral Complications Clinical Modifications Suction, Suction, Suction No water from ultrasonic or handpiece Mouth props needed 8

9 Clinical Modifications Scale back treatment expectations Instrument use: universals, sickles and restorative carving for occlusals Remove small pieces of calculus at a time Valium for you and patient! Quadriplegia Complications Respiratory function impaired Body temperature difficulty Increased sensitivity above level of injury Autonomic Dysreflexia Pressure Sores Spasticity Vulnerability to Infection Autonomic Dysreflexia Life threatening emergency when the blood pressure increases sharply Pounding headache Chills, sweats, stuffy nose, spasticity 9

10 Autonomic Dysreflexia Management Position patient upright Check bladder tubing or bag, and empty If problem continues, call 911 Clinical Care Patient should be seated as upright as possible Ask about sitting tolerance to prevent ulcers Be sure to have a dental assistant present or nurse/family assisting for suction Use extreme caution with ultrasonic or handpiece water Standard treatment is appropriate Thank you! Cindy Kleiman, RDH, BS Oral Care Consultant and Speaker (480) cindy@cindyspeaking.com 10