Effectiveness of Oral Care Protocol on Oral

Health Status of hospitalised children admitted in

Intensive Care Units of selected hospital of Haryana

Shweta Handa, Sulakshna Chand, Jyoti Sarin,Varsha A Singh, Shalini Sharma

Abstract: The importance of good oral health for intubated, unconscious patients reflects the
dimension of preventive oral care in reducing colonization of potential respiratory
pathogens.Traditionally, oral health and oral hygiene have been given low priority in the nursing care of
critically ill children.To assess the effectiveness of Oral Care Protocol (with normal saline) in terms of
Oral Health Status of hospitalized children admitted in intensive care unit (ICU), an experimental
approach was adopted with pre-test post-test control group design. A sample of 60 hospitalized
children admitted in ICU was selected by purposive sampling technique were randomly assigned to
control and experimental group. Data in terms of Oral health status and microbiological colony count
was assessed using Beck oral assessment scale and colonization scale. The Oral Health Status of
hospitalized children improved in the experimental group as compared to the control group. Oral Care
Protocol was also effective in terms of reduction of colony count of Candida albicans,
Staphylococcusaureus. However there was no significant reduction in the colony count of Coagulase
negative staphylococci, Kliebsella

Keywords Introduction
Effectiveness, oral care protocol, oral health Oral care is a fundamental aspect of
status, hospitalized children. nursing that impacts the health, well-being
and comfort of patients1.There is a complex
integration of functional oral components
Correspondence at necessary to maintain oral health and
Sulakshna Chand
wellness2.Within 48 hours of admission, the
Assistant Professor oropharyngeal flora of critically ill children
MMIN, Mullana, undergoes a change from predominantly
Ambala
gram positive organisms to predominantly
Nursing and Midwifery Research Journal, Vol-10, No.1, January 2014 8
gram negative organisms, creating more
virulent flora. Due to anatomical connection
between the oral cavity, the respiratory and
circulatory systems, pathogens potentially
transfer to cause systemic infections.
Pneumonia has been reported as the most
common infection in intensive care unit in
Pakistan, Lebanon and India with prevalence
3
of 28%, 47%, and 81% respectively.
Nosocomial pneumonia contributes to 60%
of the fatal infections and is the leading cause
of death in critically ill children4. In addition,
length of hospital stay also impacts the
mortality rate of children as there is
statistically significant increase in dental
plaque which is a potential source for dental
colonization and nosocomial infections
among children admitted in ICU for four days
or more5.
Critically ill children are usually
dependent on nurses for oral care due to their
inability to perform essential care for
themselves. Assessment of the oropharynx
and maintaining a favorable level of hygiene
are challenging to perform in critically ill
children. This task further becomes difficult
due to the presence of mechanical barriers
such as endotracheal tube, oral airway, oral
gastric tube, and temperature probe which
crowd the mouth of critically ill patient. In
addition, fixation tapes quickly become
heavily contaminated with pathogens in the
presence of salivary disturbances leading to
difficulties associated with cleansing of the
mouth6. As a result, nurses are often
reluctant to manipulate endotracheal tube for
oral assessment and hygiene measures.
However, assessment of oral health is
essential to establish patient's baseline oral
Nursing and Midwifery Research Journal, Vol-10, No.1, January 2014
health status during the course of care and
response to interventions. With early
assessment and detection of oral health
disturbances, oral care may be modified or
frequency of interventions adjusted to
prevent the incidence and further
deterioration which negatively impact the
children's overall health7.Thus,consistent
efforts to improve oral care in the intensive
care unit are important and the provision of a
well-developed oral care protocol can
improve the oral health of patients admitted
8
in the intensive care unit .
Objective
To assess the effectiveness of Oral Care
Protocol in terms of Oral Health Status of
hospitalized children admitted in intensive
care units.
Materials and Methods
A quasi experimental research design
was adopted to assess the effectiveness of
Oral Care Protocol in terms of Oral Health
Status of hospitalized children admitted in
intensive care units.
The tools for data collection were:
demographic and clinical variables. Oral
health assessment score was calculated
using Beck Oral health assessment scale
(standardized scale) with scores ranging
from 5-20 (higher scores indicating poor oral
health status). The scores were categorized
as 1-5 (No dysfunction), 6-10 (Mild
dysfunction), 11-15 (Moderate dysfunction),
16-20 (Severe dysfunction). Oral
microbiological colony count was done
which included: Coagulase negative
staphylococci, Klebsiella, Candida albicans,
and Staphylococcus aureus. The colony
count was categorized into: Confluent
9
Growth (>200 CFU), Moderate Growth (100-
200 CFU), Moderate Scanty Growth (20-99
CFU), Scanty Growth (< 20 CFU). The tools
were validated by nine experts from
concerned fields of; Child Health Nursing,
Medical-Surgical Nursing, Pediatric
Medicine, Microbiology Department, Dental
department. Oral care protocol is an
appropriate method to assist the clinical
nurses by providing analytical framework for
providing oral care to hospitalized children.
Beck oral assessment scale was primarily
accomplished by Beck which included 41
items pertaining to assessment of lips,
gingival/oral mucosa, tongue, teeth and
saliva. Scores ranges from 5-20 with higher
scores indicating poor oral health status.
Firstly the protocol was developed which
included 29 items which primarily focused
on oral care with disinfectant for four times a
day (including inner tooth surface first, outer
tooth surface, roof, gums, inside cheeks and
tongue) for implementation of oral care to
the hospitalized children.
The target population included
hospitalized children admitted in intensive
care units in the months of December 2012
to January 2013. Sixty hospitalized children
admitted in intensive care unit i.e. for
experimental group (30 subjects) and
control group (30 subjects) were selected by
purposive sampling technique and were
randomly assigned to experimental and
control group. Comatose hospitalized
children between the age group of one year to
12 years admitted in intensive care units for
more than 48 hours, available at the time of
data collection and whose parents gave
consent for participation of their children in
Nursing and Midwifery Research Journal, Vol-10, No.1, January 2014
study were included in the study. Pilot study
was conducted in Maharishi Markandeshwar
Institute of Medical Sciences Research &
Hospital (MMIMSR&H) for assessing the
feasibility of the study.Data was collected
after obtaining formal administrative
approval from the designated authority.Data
was collected from December 2012 to
January 2013.Informed consent was
obtained from the parents of respondents
after explaining the purpose of the study and
ensuring confidentiality of their response.
After recruiting the subjects for the
study, demographic and clinical details were
collected. On day one, Oral health
assessment was done using Beck oral
assessment scale (standardised) and
obtaining gingival swab from the oral cavity
of hospitalized children in experimental and
control group for oral microbiological colony
count. The obtained swab was transported
and inoculated in blood agar. Microbiological
flora was identified using gram staining and
microbial colonies were counted using
colony counter and recorded in oral
microbiological recording sheet.
After initial assessment and specimen
collection, experimental group received oral
care based on prepared protocol i.e. oral care
with normal saline four times a day for three
consecutive day (including inner tooth
surface first, outer tooth surface, roof,
gums, inside cheeks and tongue) and
control group received routine oral care.
On day four, oral health assessment
was done using Beck oral assessment scale
and obtaining gingival swab from the oral
cavity of hospitalized children in
experimental and control group for oral
10
microbiological colony count. The obtained
swab was transported and inoculated in
blood agar. Microbiological flora was
identified using gram staining and microbial
colonies were counted using colony counter
and recorded in oral microbiological
recording sheet. Final data was collected and
analyzed using both descriptive and
inferential statistics. Statistical analysis was
done by SPSS version 17.0.
Results
Table1: Data presented in table-1
revealed that 33.4% of subjects in
experimental group and 50% of subjects in
control group were in the age group of 4-6
years. Both in experimental and control
group, 56.6% of subjects were males. In
experimental group, 33.4% of subjects were
diagnosed with respiratory problem as
compared to 30.2% of subjects in control
group. Maximum number of the subjects in
experimental group and control group were
not receiving antiepileptic drugs (90%),
(96.6%), corticosteroids (86.6%), (83.4%),
antihistamines (93.4%), (90%) respectively.
All the subjects (100%) in both the groups
were receiving antibiotics. In both the groups
63.3% of subjects were with traction and
other supportive device.The computed chi
square values were not found to be
significant (p>0.05).This indicated that
subjects in the experimental group and
control group were homogenous with regard
to age, gender, diagnosis, prescribed
medication, presence of nasogastric
tube,ventilator support and supportive
devices.
Nursing and Midwifery Research Journal, Vol-10, No.1, January 2014
Table 2: Data presented in table 2
revealed that in experimental group, the
mean oral health assessment score of
subjects was 13.77 and 9.67 before and after
implementation of oral care as per protocol
respectively with a mean difference of 4.10.
The computed't' value of 9.17 was found to
be statistically significant at 0.05 level.
The data also revealed that in control
group, the mean oral health assessment
score of subjects was 12.93 and 13.00
before and after implementation of routine
oral care respectively with a mean difference
of 0.06. The computed ' t' value of 0.31 was
not found to be statistically significant at 0.05
level.This showed that there was significant
difference between the mean oral health
assessment score of subjects before and
after implementation of oral care protocol.
Data further revealed that before
implementation of oral care, the mean oral
health assessment score of subjects was
13.77 in experimental group and 12.93 in
control group with a mean difference of 0.83.
The calculated 't' value of 1.27 was not found
to be statistically significant at 0.05 level.
This indicated that the subjects in
experimental and control group did not differ
initially in terms of oral health assessment
scores. The findings also revealed that after
implementation of oral care, the mean oral
health assessment score of subjects was
9.67 in experimental group and 13 in control
group with a mean difference of 3.33. The
calculated 't' value of 6.44 was found to be
statistically significant at 0.05 level of
significance. Thus, it can be inferred that oral
care as per protocol was effective in reducing
oral health assessment score of subjects.
11
 Table1: Characteristics of Subjects in Experimental and Control Group
N =60
2
Sample Experiment Control group df c
Characteristics Group (n=30) (n=30)
f(%) f(%)
Age in years
1-3 yrs 06 (20.0) 01 (3.4)
4-6 yrs 10 (33.4) 15 (50.0)
NS
7-9 yrs 07 (23.3) 11 (36.6) 3 02.43
10-12 yrs 07 (23.3) 03 (10.0)
Gender
Male 17 (56.6) 17 (56.6)
Female 13 (43.4) 13 (43.4)
Diagnosis
Respiratory system 10 (33.4) 09 (30.2)
Renal system 04 (13.4) 05 (16.6)
NS
Gastrointestinal system 02 (6.6) 02 (6.6) 5 1.62
Neurological system 04 (13.4) 02 (6.6)
Musculoskeletal system 08 (26.6) 11 (36.6)
Integumentary system 02 (6.6) 01 (3.4)
Prescribed Medication
Anti-epileptic drugs
Yes 03 (10) 01 (3.4) 1 1.64NS
No 27 (90) 29 (96.6)
Corticosteroids
Yes 04 (13.4) 05 (16.6) 1 0.13NS
No 26 (86.6) 25 (83.4)
Antibiotics
Yes 30 (100) 30 (100)
Antihistamines
NS
Yes 02 (6.6) 03 (10.0) 1 0.21
No 28 (93.4) 27 (90.0)
5. Client with
Nasogastric tube 03 (10.0) 04 (13.4)
Ventilator support 08 (26.7) 07 (23.3) 2 0.25NS
Other supportive devices 19 (63.3) 19 (63.3)
c (1)=3.84), (2)=5.99, (3)=7.81, (5)= 11.07 ; NS - not significant (p>0.05)
2

Nursing and Midwifery Research Journal, Vol-10, No.1, January 2014 12

 Table 2: Oral Health Assessment Score of Subjects in the Experimental and Control
Group Before and After Implementation of Oral Care Protocol.
N =60
Group Before oral care After oral care MD,SD,SE, P
Mean oral Mean oral t value
assessment score assessment score
Experimental 13.77 9.67 4.10, 2.26, 0.49 0.001
(n=30) 9.17*
Control 12.93 13.00 0.07, 1.17, 0.69 0.757
NS
(n=30) 0.31
MD, SD, SE, 0.83, 2.09, 0.67 3.33, 2.39, 0.47,
NS
t 1.27 6.44*
P value 0.209 0.001
t (29)=2.05; *significant (p0.05), NSNot significant (p>0.05). t (58) = 2.00;
Table 3: Data presented in table 3 was not significant at 0.05 level of
revealed that in experimental group the significance. It was concluded that the Oral
computed 't' value for Candida albicans and Care Protocol was effective in reducing
Staphylococcus aureus [t (29)= 6.54] and colony count of Candida albicans,
[t (29)=9.83] was found to be significant at Staphylococcus aureus whereas not
0.05 level of significance whereas 't' value effective in reducing colony count of
for Coagulase negative staphylococci and Coagulase negative staphylococci, Kliebsella
Kliebsella [t (29)=1.49] and [t (29)= 1.74]
Table 3: Oral Microbiological Colony Count of Subjects before and after implementation
of Oral Care in Experimental and Control Group
N =60
Oral Group Mean Oral MD, SEMD, SDD 't' value,
microbiological microbiological flora
flora Count
Before After oral
oral care care
NS
Coagulase Experimental 151.26 150.66 0.60, 91.05, 2.29 1.49 . 0.141
negative Control 179.17 181.07 1.90, 191.84, 7.35 1.41NS. 0.163
staphylococci
Klebsiella Experimental 188.13 187.46 067, 57.48, 2.09 1.74NS. 0.087
NS
Control 194.03 191.27 2.76, 83.36, 34.24 0.44 . 0.661
Candida albicans Experimental 218.23 163.86 54.37, 38.90, 45.47 6.54*, 0.001
Control 220.47 220.87 0.40, 230.39, 3.04 0.71NS. 0.480
Staphylococcus Experimental 182.60 141.37 41.23, 19.10, 22.95 9.83*, 0.001
aureus Control 175.70 176.33 0.63, 124.65, 1.90 1.82NS 0.073
t(29)=2.05; NS Not significant (p>0.05), *significant -(p0.05)
Nursing and Midwifery Research Journal, Vol-10, No.1, January 2014 13
Discussion
Hospitalization has been found to
negatively impact overall oral health as
evidenced by increased dental plaque
accumulation together with deterioration in
mucous membranes and gingival
inflammation in critically ill children. The
importance of good oral hygiene for children
with toothpaste, chlorhexidine gluconate,
normal saline, sodium bicarbonate,
hydrogen peroxide, lemon and glycerine
swabs are recommended to provide oral care
for children admitted in intensive care unit.
9 microbes and maintaining the oral health
The present study findings indicated
that oral care protocol i.e. in changing month
with normal saline 4 times a day was effective
in reducing oral health assessment score and
reducing the colony count of Candida
albicans, Staphylococcus aureus whereas no
effect on reducing the colony count of
Coagulase negative staphylococci,
Klebsiella. These findings are consistent with
the findings of the study reported by Nancy J.
10
Ames (2011) which revealed that oral health
assessment scores reduced after nurses
implemented a protocol for systematic oral
care.
The present study findings also showed
that oral care with normal saline was effective
in maintaining the oral health of hospitalized
children. These findings are consistent with
the findings of the study which revealed that
normal saline was effective in maintaining
the oral health status of hospitalized children
11
Kim YK, Choi SH (2003)
The present study findings revealed that
oral care protocol was effective in reducing
oral health assessment scores and oral
Nursing and Midwifery Research Journal, Vol-10, No.1, January 2014
microbiological flora of hospitalized
children. These findings are in line with the
findings of the study conducted by Randa
FA12(2007), Ali H13(2012), Kim LS14(2010),
Sazlina SG15(2012), Hadi R16(2011), Angela
MB 1 7 (2006), Olivia S 1 8 (2011), Laura
19
A (2010), which revealed that well
developed oral care protocol by bedside
nurses can improve the oral health of
patients admitted in intensive care unit.
These studies also revealed that oral care
protocol was effective in reducing the
status of hospitalized children. Thus, oral
care protocol was effective in improving the
oral health status of hospitalized children.
Hence it is recommended that the use of an
assessment model such as the BRUSHED
Assessment Model is recommended for the
immediate identification of oral problems for
all patient and should be carried out daily
followed by regular oral care. The study can
be replicated on a larger sample to validate
the findings and make generalizations.
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