To p i c s i n

Progressive Care

Brush up on oral assessment and care

By Allan J. Schwartz, DDS, CRNA, and Sherry Powell, RDH

A
A CRITICALLY ILL PATIENT needs frequent oral
assessment and care to avoid complications caused
by oropharyngeal bacteria. Because the head and
neck command a large portion of the body’s blood
supply, infection can quickly spread throughout the
body, making early detection of possible problems
important to help keep your patient healthy. In this
article, we’ll take a look at how to perform oral
assessment and care.
ous infections. Aggregated bacteria excrete an
adhesive matrix and form a substance called
plaque that causes tooth decay.4
Oropharyngeal microorganisms are most thor-
oughly and effectively removed by mechanically
cleaning the teeth, gums, and tongue with a soft
toothbrush and using an antibacterial toothpaste
and oral topically applied antimicrobials. Patients
who are endotracheally intubated should have their
subglottic areas suctioned frequently because bacte-
Why is oral care important? rially contaminated oral secretions may leak around
Without properly performed oral assessment and the ET tube and find an environment that supports
care, a critically ill patient can experience complica- the growth of these pathogenic bacteria.
tions that may lead to a longer hospital stay, signifi- Patients who are endotracheally intubated are
cantly increased costs of care, and even death.1 A especially vulnerable to VAP. The ET tube is usual-
critically ill patient’s individual requirements for ly held in place with either tape or a commercial
oral care should be considered as part of the admis- ET securement device, which provides a breeding
sion assessment.2 Nurses may be reluctant to per- ground for potentially pathogenic bacteria and pre-
form oral care for various reasons, such as fear of vents easy access to the mouth for cleaning.
dislodging an oral endotracheal (ET) tube, but these Carried along by saliva, pathogens can migrate
barriers must be overcome to enable essential nurs- down the ET tube through the space between the
ing care.3 (See Barriers to proper oral care in critically ill tube and the vocal cords, down the trachea, and
patients.) into the lungs or directly down the ET tube. VAP is
The mouth is host to many bacteria, viruses, and most commonly caused by Gram-negative enteric
fungi, even in a healthy indi-
vidual. If left unchecked, these
potentially harmful pathogens
become opportunistic in the
oral cavity’s dark, warm, and
moist environment and can
cause both local and systemic
complications. Multiplying
quickly, they can cause caries,
halitosis, periodontal inflam-
mation and infection,
osteomyelitis of the maxilla
and mandible, ventilator-asso-
ciated pneumonia (VAP), and
septicemia if they’re not
removed properly. Critically
ill patients also have impaired
immune responses, making
them more vulnerable to seri-

www.nursing2009criticalcare.com November l Nursing2009Critical Care l 7

 Barriers to proper oral care in
critically ill patients
• fear of dislodging the patient’s ET tube
• fear of aspiration
• fear of adding to the patient’s discomfort
• the nurse’s time constraints
• lack of knowledge of proper oral assessment and
care
• perception that oral care has a low priority for criti-
cally ill patients
bacteria and two species of normal oral flora,
Pseudomonas aeruginosa and Staphylococcus aureus.5
Start with assessment
Assess the patient’s gingiva daily for signs of dis-
ease. Note the tissue’s color, size, shape, consis-
tency, and surface texture. Diseased gingiva may
appear bright red, enlarged, bulbous, spongy,
smooth, and shiny. Also look for ulcerations on
the oral mucosa and assess the teeth, lips, and
tongue. (See The BRUSHED oral assessment tool for
more details.) Document your findings.
Time for a cleaning
Once you’ve completed your assessment and are
ready for cleaning, gather the following supplies:
• clean gloves
• protective face mask
• protective eyewear for the patient and for you
• 0.12% chlorhexidine gluconate (only for adult
perioperative cardiac surgery patients)
• pediatric-sized or adult-sized toothbrush with
soft bristles (foam swabs are ineffective for
removing plaque)
• antibacterial toothpaste
• alcohol-free mouth rinse
• petroleum jelly
• oral moisturizing gel
• roll of 1-inch (2.5-cm) tape
• flashlight
• clean Yankauer suction tip and clean suction
tubing.
Note the depth of the ET tube in relation to a
facial landmark and secure it to the side of your
patient’s face with tape. Teeth, gums, and tongue
need to be brushed twice a day. In addition to
brushing, oral moisturizing should be provided to
oral mucosa and lips every 2 to 4 hours.6
8 l Nursing2009Critical Care l Volume 4, Number 6
The BRUSHED oral
assessment tool8
Use this mnemonic device to help you perform a thor-
ough and systematic assessment of your patient’s
mouth.
B leeding (gingiva, oral mucosa, patient’s coagula-
tion status)
R edness (gingiva, tongue, dry mouth, antibiotic
stomatitis)
U lceration (size of ulcer, shape of ulcer, herpetic
ulcers, aphthous ulcers)
S aliva (thin/watery, thick, copious amounts, dry
mouth)
H alitosis (character, absence of)
E xternal factors (cracks and redness at corners of
the mouth, ET tape or commercial ET tube secure-
ment device, cleanliness)
D ebris (visible plaque, foreign substances, pres-
ence on ET tape or ET tube securement device)
To begin, explain to the patient that you’ll clean
her mouth with toothpaste and mouth rinse and
apply petroleum jelly to her lips. Carefully open
her mouth with gloved fingers.
Gently brush all surfaces of the teeth, gums,
and tongue in a circular motion, using an antibac-
terial toothpaste. If the patient doesn’t have teeth,
brush her gums and tongue gently. Rinse the
toothpaste from the patient’s mouth with an alco-
hol-free mouth rinse using an irrigation syringe
or swab and suction as needed. Apply a pea-sized
amount of oral moisturizing gel to a gloved finger
and gently massage it into the mucous mem-
branes of her mouth. Put petroleum jelly on a
gloved finger and apply it to her lips.7
An oral chlorhexidine gluconate (0.12%) rinse
should be used twice a day during the periopera-
tive period for adult patients who undergo car-
diac surgery. Routine use in other populations
isn’t recommended.6
Document carefully
Once you’ve completed cleaning, document any
suspicious oral exudate, odors, red tissue, bleed-
ing, ulcerations, or other abnormalities you see in
the patient’s mouth. Record the frequency of oral
care, differentiating between comprehensive oral
care (including brushing) and oral moisturizing.
Providing frequent oral assessment and care will
help your patient avoid serious complications. ❖
www.nursing2009criticalcare.com
 Call for manuscripts
®

REFERENCES We’re looking for manuscripts for Nursing2009

1. Cason CL, Tyner T, Saunders S, Broome L. Nurses’ implementation
of guidelines for ventilator-associated pneumonia from the Centers
for Disease Control and Prevention. Am J Crit Care. 2007;16(1):28-37.
2. Abidia FR. Oral care in the intensive care unit: a review. J Con-
temp Dent Pract. 2007;8(1):76-82.
3. Jones H, Newton JT, Bower EJ. A survey of the oral care practices
of intensive care nurses. Intensive Crit Care Nurse. 2004;20(2):69-76.
4. Haake SK, Newman MG, Nisengard RJ. Carranza’s Clinical Peri-
odontology. 9th ed. Philadelphia, PA: WB Saunders; 2002:96-99.
5. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guide-
lines for preventing health-care-associated pneumonia, 2003. http://
www.cdc.gov/ncidod/dhqp/pdf/guidelines/CDCpneumo_guidelines.pdf.
6. AACN Practice Alert: Oral care in the critically ill. http://www.
aacn.org/WD/Practice/Docs/Oral_Care_in_the_Critically_Ill.pdf.
7. Fitch JA, Munro CL, Glass CA, Pellegrini JM. Oral care in the
adult intensive care unit. Am J Crit Care. 1999;8(5):314-318.
8. Hayes JH, Jones C. A collaborative approach to oral care during
critical illness. Dent Health. 1995;34(3):6-10.
Allan J. Schwartz is a dentist at ProDental in Columbia, Mo., and a certified
registered nurse anesthetist with St. Elizabeth’s Hospital in Belleville, Ill.
Sherry Powell is a dental hygienist in Columbia, Mo.
Adapted from Schwartz AJ, Powell S. Brush up on oral assessment and care.
Nursing. 2009;39(3):30-32.
Critical Care. If you’d like to write about some practi-
cal aspect of critical care that would interest other
nurses in this field, or a short non-clinical article
about a challenging or memorable patient or experi-
ence, please send us a topic query letter or e-mail.
Typically, we look for short, focused articles that read-
ers can apply to their clinical practice or patient educa-
tion. So if you’ve been thinking about trying your hand
at having an article published, why not give it a try?
Start by getting a copy of our standard author
guidelines. You can access them online at www.
nursing2009criticalcare.com (click on "About this
publication") or request a copy by calling Barbara
Miller at 215-628-7789 or by e-mailing her at
barbara.miller@wolterskluwer.com.
Then send your topic query to Jan Corwin Enger,
managing editor, at jan.enger@wolterskluwer.com or
submit your manuscript to Nursing2009 Critical Care
via www.lwwesubmissions.com. We look forward to
hearing from you!

Now, banking that

gives back to those
who give so much.
Exclusively for Nurses from Bank of America.
Earning WorldPoints® rewards is easy with the Nursing Visa® credit card. Every
purchase you make earns points toward great rewards like travel, cash, and brand-
name merchandise. And you can display pride in being a nurse every time you use it.
Call 1.866.598.4970 or visit newcardonline.com and use Priority Code UAAKIA.

For information about the rates, fees, other costs and benefits associated with the use of this credit card, or to apply, call the toll-free number above, go to the Web site
listed above, or write to P.O. Box 15020, Wilmington, DE 19850. This credit card program is issued and administered by FIA Card Services, N.A. Visa is a trademark of
Visa International Service Association and is used by the issuer pursuant to license from Visa U.S.A., Inc. Platinum Plus is a registered trademark of FIA Card Services, N.A.
Bank of America and the Bank of America logo are registered trademarks of Bank of America Corporation.
©2009 Bank of America Corporation AD-06-09-0070.A

www.nursing2009criticalcare.com November l Nursing2009Critical Care l 9