Ventilator Associated Pneumonia and Oral Health Hygiene

by Jason Shaw


Oral wellbeing functions like a mirror of the body, showing what is truly going on inside. Various systemic diseases of the body such as stroke, coronary diseases, diabetes and pneumonia are sometimes correlated with the oropharyngeal region. Most of these disorders also contribute to dire outcomes. Therefore, their oral health treatment should be paid heed to by all. One of the more prevalent diseases that exists as a result of bad oral hygiene is pneumonia. Older persons who are too lazy, too weak or rely on others to maintain proper oral health are people who are at risk of acquiring this disease. Patients undergoing artificial ventilation also acquire a form of pneumonia, which is ventilator-associated pneumonia. In chronically ill people, this is the primary cause of morbidity and mortality. The use of a mixture of pharmacological and mechanical approaches is an important way of minimising the production of VAP in patients. The mechanical procedure utilised is teeth brushing, whereas the pharmacological technique requires the application of an efficient bactericidal agent, Chlorhexidine. The role of nurses in the introduction of good oral hygiene is often very significant, in particular for those in long-term care facilities. There are several papers discussing the effective procedures for assessing, intervening oral care activities, and several of them are done on duty by the nursing personnel.

Ventilator Associated Pneumonia and Oral Health Hygiene

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The World Health Organisation identifies oral health as free from any type of chronic mouth and facial pain, oral and throat cancer, oral sores, birth defects such as cleft palate or lips, periodontal gum disease, tooth decay or tooth loss, and many other diseases and disorders of the oral and mouth cavity (, 2015). Oral hygiene is not about good teeth; the mouth should be used as a mirror that provides a view into a human being’s overall health. The presence of gum or tooth tissue may signify the presence of diseases, the development of the disease, or the risk of developing those diseases. Oral cells and fluids are being used progressively to detect different diseases (, 2014). A association between gum diseases and stroke, heart diseases and premature babies with low birth weight is shown in the latest studies. Likewise, almost 90% of the disorder has oral signs and symptoms (, 2012). The immune function of the body is thereby reduced by HIV/AIDS and diabetes, raising the incidence of oral diseases. Endocarditis, a heart condition that is triggered by bacteria accessing the bloodstream from the teeth, is often known to be correlated with bone loss and tooth loss (, 2013). It may induce pneumonia if salivary secretions containing bacteria are sucked into the lower respiratory tract. Like the oroharyngeal cavity in the lower airway, this micro-organism aspiration emerges from the proximal location. The surfaces of the teeth are vulnerable to plaque accumulation that can contribute to respiratory pathogens being colonised. Those that have bad oral hygiene are also more likely to experience respiratory infections (Burket, Greenberg, Glick & Ship, 2008). The type of pneumonia that occurs in patients undergoing mechanical ventilation may be described as Ventilator Associated Pneumonia (VAP). Colonization of mainly Staph aureus and Strep Pneumoniae microorganisms or other gramme negative rods in the oropharyngeal area leads to the growth of VAP (Munro, Grap, Jones, McClish & Sessler, 2009). An campaign identified as Safe Citizens sets a 10-year target to strengthen the wellbeing of Americans at the national level. This programme seeks to establish a society where everybody lives a healthy and prosperous existence (, 2015). Progress on Healthier People 2020 has been promising, with a range of milestones met in the first part of the year. 15.4% have achieved the 2020 target of healthier individuals, while 38.5% are also on the path to meeting their targets, 30.8% are still as they were when the campaign was introduced, 3% are deteriorating, while just 1% are on borderline data (, 2015). Oral hygiene is one of the factors used in the categories of becoming worse, 44.5 percent of persons have daily dental visits to the dentist in 2007, although in 2011, this figure fell to 41.8 percent, suggesting that oral health declined by 6.1 percent (, 2015). People who are at greater risk of having VAP are those that need mechanical health (, 2015). (Lewis, Dirksen, Heitkemper, Bucher, Camera, 2014). Bad oral treatment given to patients who are in hospital or nursing homes with long-term stays may have dire effects, such as stroke, coronary disorders, and pneumonia. A Canadian research shows that there is a strong correlation between respiratory and periodontal diseases and that proper oral hygiene practise greatly decreases the prevalence of respiratory diseases in geriatric patients. Another research found that those with periodontal disorder ultimately experience cardiovascular problems in the form of stroke, angina, and myocardial infarction (Stein & Henry, 2009). Their teeth grow brittle and often darken in colour when an individual grows older. Aging persons appear to lose more teeth and can even lose the supporting tissues and bone. The amount of infections, which are mainly attributed to poor oral hygiene habits, is also growing with a rise in age. Mouth dryness may contribute to diabetes mellitus. Failure to swallow food can result in aspiratory pneumonia (Heath, 2011). Recommendations for implementation from the Society for Health Epidemiology of America and Infectious Diseases Society of America note that infection prevention and management procedures should be applied at all times possible; this involves hand hygiene, aseptic strategies during fluid suction and when handling respiratory equipment. The oral treatment of a ventilator patient needs examination, both before and after oral care is given. When the patient is brought into the unit and even with each oral treatment move, the examination can be conducted by a nurse. Ultimately, under the guidance of a registered nurse, a licenced practising nurse can conduct the role at hand (Booker, Murff, Kitko & Jablonski, 2013). Testing that the lips and mucosa are neat, tidy, gentle, intact and moist is the intention behind the examination. To recognise and to intervene, assessment is needed and then review the improvement. The assessment may be carried out using different devices, such as the Jenkins Oral Calculator (Malkin, 2009). As they are responsible for delivering oral health care to patients of all sorts, whether they are dependent, autonomous or unaware, the role of nurses in ensuring good oral hygiene is critically significant. The nurses are well briefed regarding the tradition of preserving good oral hygiene; they also recognise the procedure for maintaining good oral hygiene (Potter, P. & Perry, A.G., 2010). In order to improve people’s understanding of good oral health, Canada founded the Chief Dental Officer’s Office in 2004. While nurses are well conscious of the techniques used to ensure proper oral hygiene, doctors have been lacking in diagnostic knowledge (Yoon, 2011). Two strategies are used in the current evidence-based practise to eliminate VAP; the first is active action by the use of pharmacological agents that destroy bacteria, while the second strategy is to kill the bacteria through mechanical approaches such as teeth brushing. For those requiring artificial breathing, the Center for Healthcare Reform has suggested the usage of regular oral treatment of chlorhexidine (Munro, 2014). With the assistance of the dental hygienist faculty, the basic procedure for mechanical cleaning or tooth brushing of the mouth was established and recommended by the American Dental Association. The patient’s mouth had to be separated into 4 parts or quadrants, i.e. the upper right, lower right, upper left, and lower left. It defined the tooth brushing pattern. On the lingual, biting surfaces, each quadrant was rubbed with five strokes and on the oral side with a gentle toothbrush and tooth paste. They can even clean the palate and tongue. Any area is then rinsed with a mouthwash ideally Biotene, with the aid of a transfer pipette 2.5ml for each area and finally with the help of a green toothette swab a moisturising gel was added to all surfaces. In a related process, chlorhexidine was often added using the green toothette swab to cover the tooth, tongue and palate evenly (Munro, Grap, Jones, McClish & Sessler, 2009). Some old EBP methods involved remaining in a supine posture for the first 24 hours with mechanical ventilation for the patient, but compliance with this approach is poor. In order to clear the stomach and oropharyngeal area, some researchers have often promoted the use of antibiotics, although this is now an obsolete approach since the use of antibiotics may contribute to anti-microbial resistance. ETT and suctioning of the Subglottic can also stop the incidence of VAP in addition to this vigilant oral (O’Keefe-McCarthy, Santiago & Lau, 2008).


The most powerful technique that has an anti-plaque benefit is chlorhexidine. It is a wide-ranging antiseptic agent with a bactericidal effect. Studies have shown that plaque formation is decreased by 50 to 60 per cent (Cappelli & Mobley, 2008). The common people who are more prone to developing bad oral health include unhealthy people, obese, stress, lack of exercise and smoking. It also has a relation with the status of the person. Dental caries usually occur in people who are socially deprived (Kirch, 2008). Children who are of low income are more prone to develop dental problems. If a child’s poor oral health is not properly addressed then it might lead to diminished growth in toddlers and a compromise in nutrition. They are also more prone to develop infection like the common cold or ear infections. If the risk factors are not assessed or diagnosed in proper time then it may lead to serious health consequences in the form of chronic diseases (, 2014). It may contribute to dental caries, gingivitis, periodontitis, xerostomia, candidiasis and oral cancer if the risk factors are not tested in the elderly (GONSALVES, WRIGHTSON & HENRY, 2008). Not only are the nurses responsible for ensuring good oral hygiene, they are often responsible for designing and administering procedures used to preserve good oral hygiene, such as exercising for obese patients, although older patients may need a longer pre-exercise warm-up session, such as stopping smoking. In order to accomplish these objectives, nurses have to direct the patient by establishing goals and reminding the patient of different relevant services that the patient may use (Martucci & Gulanick, 2012).

The report, Evidence-based nursing methods to avoid ventilator-acquired pneumonia, addresses the possibility of ventilator-acquired pneumonia being produced by manually ventilated patients. Tactics can be followed by critical care nurses operating with intubated patients to prevent the outbreak of ventilator-acquired pneumonia. VAP comes from the aspiration of micro organisms producing secretions. The application of chlorhexidine in intubated patients appears to minimise the incidence of VAP (O’Keefe-McCarthy, Santiago & Lau, 2008).

The Oral Health article: Something to rejoice over! Discussions on the connection between a human being’s oral health and general health and how a number of chronic systemic diseases may be induced by bad oral health. The article is based on descriptive and observational researches that tell the importance of dental plaque and its relation with ventilator associated pneumonia. The study conducted proved efficient in reducing the occurrence of VAP among mechanically intubated patients. The use of chlorhexidine after intubation was very successful in avoiding VAP in intubated patients (Munro, 2014).

The third and last article Chlorhexidine, toothbrushing and preventing ventilator associated pneumonia in critically ill adults discusses the various methods of maintaining oral hygiene’s and the efficiency of mechanical and pharmacological cleaning in oral care in patients who are receiving mechanical ventilation. The research concluded that pharmacological method of maintaining oral hygiene was more effective in avoiding VAP whereas the mechanical method of tooth brushing was not as effective (Munro, Grap, Jones, McClish, & Sessler, C. 2009).

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