oral managements for hospitalized...

ORAL MANAGEMENTS FOR HOSPITALIZED PATIENTSBy : Dr. Elahe Ghasemzade Hosseini

In The Name Of Allah

Dr.

Ela

he

Gh

ase

mza

de

Ho

sse

ini

Nosocomial pneumonia is the

second most common

infection (after infections of

the urinary tract ) in long-termcare institutions. It accounts

for approximately 10% to 15%

of all hospital-acquired

infections, and 20% to 50% of

affected patients will die

because of the infection.

mortality rates among

institutionalized patients from

pneumonia are reported to

be as high as 41%.

VAP is a relatively common nosocomial

infection in critically ill patients, with a

reported prevalence ranging between

6%- 52% with some indications

Medically compromised

patients in ICUs or in

nursing homes, especially if

they are dentate, are at

risk of pneumonia, which

can be prevented by

professional oral hygiene

interventions and frequent

health care.

Aspiration Pneumonia occurs in surgical

patients and increases morbidity, mortality,

and cost of care.

Micro-aspiration of

pharyngeal secretions

may also occur around an

imperfect seal of the cuff

of the endotracheal tube

in a ventilated patient !

Two routes exist for oral microorganisms to reach the lower respiratory tract:1- Hematogenous spread (as an inevitable adverse effect of some dental treatment) 2- Aspiration This later is important in respiratory

disease In healthy patients, the distal airway and lung parenchyma are sterile, despite the heavy bacterial load (106 aerobic bacteria and 107 anaerobic bacteria per millilitre) found in the upper airway. An infection occurs when the host’s defences are compromised, the pathogen is particularly virulent or the inoculum is overwhelming.

The micro-organisms may enter the lung by

inhalation, but the most common route of

infection is aspiration of what pneumologists

have long referred to as oropharyngeal

secretions !

1.Periodontal Disease or poor

oral hygiene might result in a

higher concentration of oralpathogens in the saliva

2.Dental Plaque could harbor

colonies of pulmonary pathogensand promote their growth.

3.The proximity of tongue to the

lungdebris on the tongue is more likely to be aspirated into the lungs compared to debris on the teeth.

Mechanisms of infection related

to aspiration:

In a study approximately

40% of their intensive care

patients, dental plaque was

colonized by aerobic

respiratory pathogens.

Within 48 hours of admission

to the intensive care unit

(ICU), oral flora of critically ill

patients undergoes a change

to predominantly gram-

negative flora that includes

more virulent organisms.

Anaerobic and Gram negative

species of plaque > invasion +

bacterial Toxins > immune

system overreaction(neutrophils

degranulation,proteolytic

enzymes, …) > connective

tissue alteration and

periodontal disease.

Periodontal diseases result in

a higher concentration of

Gram-negative and anaerobic

oral pathogens in saliva as well

as in patients with neglected

oral hygiene.

The pathogens would then

be aspirated into the lung,

overwhelming the immune

defenses.

• Actinobacillus

actinomycetemcomitans

• Fusobacterium nucleatum

• Pseudomonas aeruginosa

• Bacteroides gingivalis

• Streptococcus intermedius

• Staphylococcus aureus

• Streptococcus pneumonia

• gram negative rods

Bacterial coinfection in the respiratory tractinvolving S. aureus, S. pneumoniae, and H.influenza commonly occurs. S. aureus with theinfluenza virus have a high fatality rate specially in

the elderly.

1) Alteration of receptors on the surface of the mucosal cells to promote adhesion of pulmonary pathogens.2) Degradation of the salivary pellicle coating pulmonary pathogens3) Degradation of Fibronectin4) cytokines and other molecules

PATHOPHYSIOLOGY

1. presence of a large variety

of cytokines and other

biologically active molecules.

2. peripheral mononuclear

cells may alter the

respiratory epithelium and

promote colonization by

respiratory pathogens

Effects of cytokines and other

molecules:

3.Salivary proteolytic enzymes (mannosidase, fucosidase, hexosaminidase,sialidase)

modify respiratory tract mucosal surfaces and promote adhesion and colonization by respiratory pathogens. source of these salivary enzymes(originated

from the gingival

sulcus/pocket) has been

attributed to both the oral microbiota and polymorphonuclear leukocytes.

The worse the oral hygiene & the poorer the

oral condition, the higher the enzymatic activity

& greater mucosal changes will be , resulting in

respiratory pathogens adhesion.

Hydrolytic enzymes from

periodontopathic bacteria

(like P.gingivalis) may destroy the

salivary film that protects against

pathogenic bacteria.

4.Immunoglobulins and

Antimicrobial Enzymes

(lactoferrin, lysozyme,

lactoperoxidase

statherin,histatins) is of

fundamental importance in

maintaining health & regulating

microbiome.

108 microorganisms have been detected per

milliliter of saliva, mostly derived from oral

mucosal surfaces such as the tongue.

5. The cryptic virus receptors in

the oral pharynx mucous

membranes are known to be

covered by salivary

components such as sialic acid,

and these receptors may be

exposed by microbial

enzymatic activities(e.g.

Neuroaminidase)

It is also possible that a lower

prevalence of infection by cold

viruses occurred in the POHC

group.

Maintaining good oral hygiene plays an important role in preventing respiratory infection as a part of the nursing regimen of elderly people, even for COVID-19

Generation of proteases by infected bacteria in the upper

airway play key role in activation of the hemagglutin (HA) to

HA1 and HA2 and in the virus infection. increase in oral bacteria

due to poor oral hygiene increase the risk of infection by

multiplication of the influenza virus. Professional oral care

reduced the level of oral bacteria and enzymatic activity ,and

that this lowered the risk of infection with the influenza virus.

The tongue has a rough and fissured surface which is an effective

colonization surface for formation of a microbial biofilm.

This is more important in hospitalized adults who have impaired

physical and immunological oral defenses (e.g. ineffective oral toilet,

decreased oral clearance due to low salivary flow from

polypharmacy).

90% of the dependent elderly harbored these organisms on the

tongue rather than plaque.

There are correlations between the tongue colonization of

H. influenzae and P. aeruginosa at baseline and their presence in the

sputum at time of pneumonia diagnosis. Tongue colonization by respiratory pathogens could serve as a

good proxy for the various risk factors and be used as a convenient

and accessible indicator for the risk of pneumonia development from

oral sources , because of The positive links between tongue

colonization with plaque colonization & naso-gastric feeding tube&

tracheostomy.

Three site-specific distinct

patterns were observed on:

-tongue

-hard palate

-dental plaque

suggesting that the location

of colonization of respiratory

pathogens may significantly

impact pneumonia

occurrence.

Different studies suggested cleaning of tongue

and hard palate separately in particular In

elderly population

Respiratory infections

the agent has to reach the

lower respiratory

tract

the host’s defenses must

be compromised

the pathogen must be

particularly virulent

Overwhelming

inoculum

Elderly Individuals present

alterations in the mucosa,

increasing their susceptibility

to oropharyngeal colonization

and diminishing their ability to

defend against respiratory

pathogens that way age has

been considered a risk factor

for nosocomial pneumonia and

respiratory infections.

It is essential to provide care that focuses on cleansing of the oral cavity in a regimen suitable for the elderly. There is the relationship between an individual’s length of hospital stay and their salivary flow.

Plaque colonization may be

exacerbated in the absence

of adequate oral hygiene

care.

Prolonged mouth opening

Drying of the oral cavity

Decrease in the buffering

and cleansing effects of

saliva

Salivary Secretion has a significant role in maintaining oral health and

that its suppression or diminution leads to difficulty in swallowing and

increases the risk of developing opportunistic infections by aspiration

of these pathogens ,so it is possible to aggravate the patient`s

condition and may perpetuate new infection by means of

inflammatory and immunologic intermediary factors.

milking of salivary glands is an efficient manoeuvre for balancing its

secretion.

Increased Bacterial

Colonization

Presence of the orotracheal

tube

Impossibility of self-care

Consequent formation of the biofilm & dental

plaque

Inadequate immunological

response

Low saliva flow

Decreased mastication &

tongue movement

Oral hygiene care (OHC)

Hospitalized individuals should be submitted to oral

examination for assessment of their oral condition.

those with poor oral health should be given oral health

care and monitored. Oral hygiene care (OHC), using

either a mouth rinse, gel, toothbrush, or combination,

together with aspiration of secretions, may reduce the

risk of VAP in these patients.

The typical coronavirus

structure includes the “spike

protein” in the membrane

envelope, and also other

polyproteins, nucleoproteins,

and membrane proteins, such

as RNA polymerase,

3-chymotrypsin-like protease,

papain-likeprotease, helicase,

glycoprotein, and accessory

proteins.

Structure

The S protein from

coronavirus can bind to the

receptors of the host to

facilitate viral entry into

target cell SO 2019-nCOV

can also bind to the human

angiotensinconvertingenzyme 2 (ACE2) which may

promote human-to-human

transmission .

The population with higher expression of ACE2

might be more susceptible to 2019-nCoV

because of the high affinity between ACE2 and

2019-nCoV S protein

ACE2+ cells are present

throughout the respiratory tract,

as well as the cells

morphologically compatible with

salivary gland duct epithelium in

human mouth. ACE2+ epithelial

cells of salivary gland ducts were

demonstrated to be a early

targets of SARSCoV infection,

and 2019-nCoV is likely to be the

same situation.

• ACE2 receptors are

highlyexpressed on the

mucosa of oral cavity and

are present notably in

large amounts in epithelial

cells of the tounge so

these findings indicate that

oral cavity is high risk

transmitter of 2019-n CoV

infection and this can be

prevented by oral hygine.

Dental care

cost savings1 .

Effect of oral health education and provision among the high-risk people:


improving the quality of life2 .


decreasing hospital

admissions

3 .


4 . reducing incidence of nosocomial

40 %

Interventions will most likely have greatest effect on the

incidence of early colonization and early VAP if they

are begun very early in the ICU stay.Additional strategies to reduce VAP, such as beginning

interventions earlier in the course of intubation, should

be developed and tested

Techniques for removing dental plaques and oral

pathogens:

Toothbrush

In each quadrant; every tooth

was brushed for 5 strokes on

lingual, buccal, and biting

surfaces with a soft toothbrush

3times or more daily at least

1_4 minutes

Bend the head forward and

downward while brushing to

reduce the risk of swallowing

the removed microorganisms

Tongue brush

Using sterile gauz or separate tissue paper to remove

microorganisms located on the dorsal surface of the

tongue.

Hard plate brush

Using sterile gauz

or separate tissue

paper to remove

microorganisms

located on hard

palate.

Dental floss

Using after each meal and during the day.

Edentulous adults’

people:

Professional oral health

care for elderly patients

requiring daily nursing

plays a significant role in

reducing the numbers of

potential respiratory

pathogens in the oral

cavity.

cleaning of

denture and

hard palate:

• Take out the denture

and put it in water (it

should be used only in

eating time)

• Clean all denture

surfaces

• Massage the gums

Denture

stomatitis:Candida albicans is

associated with denture

stomatitis, an inflammation

of the palatal mucosa

covered by denture.

An

gu

lar

Ch

eilitis

cleaning of denture

and hard palate and

Gargling regularly

every day with plain

sterile water or warm

normal saline

Wash the mouth with water after

using Inhalation spray

Xerostomia:

Risk factors:

-mouth opening

-drug side effect

-Immuno Compromise patient

-Changing in Content of saliva

Sy

ste

mic

Be alert!Missed diagnosis of

HSV

aphthous ulcer

SSC

Eritema multiform

aphthousulcer

Ap

hth

ou

su

lce

r

Primary HSV

Secondary HSV

Eritema

Multiform

COATED TONGUE IN POOR ORAL HYGIENE:

TASTE DISORDERS

They are continually

placed in environments

where they are

exposed to pathogens

(respiratory pathogens

readily adhere to the

mucous membranes in

the oral cavity)

They must gargle Povidone-

iodine even at very dilute

concentration or

chlorhexidine mouthwash

0.1 or 0.2 or 0.12 percent

between medical procedur.

The mucociliary clearance

of the airways and the

cough reflex are weaker in

elderly persons with

decreased ADL , so

aspiration of small amounts

of secretion from the oral

cavity tend to increase

during sleep and among

patients

Management

use appropriately-

maintained closed

suction systems and

appropriately-fitted

cuff around the

endotracheal tube.

Elevate head of bed ≥30’

Thanks For Your Attention

oral managements for hospitalized...

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