A phenomenon that skilled nursing teams have long appreciated was recently highlighted in a recent article published in JAMA Internal Medicine, researchers Ehrenzeller and Klompas shed light on a critical yet often overlooked aspect of healthcare — oral hygiene and daily toothbrushing. 

The article, titled “Daily Toothbrushing to Prevent Hospital — Acquired Pneumonia — Brushing Away the Risk,” emphasizes the significance of routine oral care in preventing hospital-acquired pneumonia (HAP), a serious concern that affects both ventilated and non-ventilated patients.

Hospital-acquired pneumonia, including both ventilator-associated pneumonia (VAP) and nonventilator HAP (NV-HAP), poses a substantial threat to patient outcomes. The root cause of HAP often lies in the aspiration of microflora from the oral microbiome, a complex ecosystem housing numerous species of bacteria, fungi, viruses, and protozoa. 

The article highlights extensive data from epidemiological, microbiological, and molecular studies establishing a clear connection between the oral microbiome, oral health, dental plaques, periodontal disease, and the development of pneumonia.

Chlorhexidine controversy

While the importance of rigorous oral care is emphasized to prevent HAP, the article acknowledges the lack of clarity in the field due to conflicting studies regarding the use of oral chlorhexidine. Despite historical use in VAP prevention bundles, recent systematic reviews and meta-analyses have shown conflicting results, leaving healthcare professionals in a quandary regarding effective prevention strategies.

Key findings

The systematic review included 15 studies with a total sample size of 2,786 patients, predominantly conducted in the ICU. The results indicate that toothbrushing was associated with a statistically significant lower rate of HAP, particularly VAP. Additional outcomes such as lower ICU mortality, shorter time to extubation, and reduced ICU length of stay were also observed in patients who underwent toothbrushing.

What knowledge can skilled nursing teams take from these lessons?

Education and training programs

Implement comprehensive education and training programs for nursing home staff, including both healthcare professionals and support staff. This should focus on the importance of oral hygiene, the correct techniques for toothbrushing and the identification of oral health issues.

Individualized oral care plans

Develop individualized oral care plans for each resident, taking into account their specific oral health needs, conditions and preferences. This approach ensures personalized attention and addresses unique challenges that residents may face.

Regular oral health assessments

Conduct routine oral health assessments for all residents, with a particular emphasis on identifying signs of dental plaques, periodontal disease or other oral health issues. These assessments can guide the development and modification of individualized care plans.

Collaboration with dental professionals

Establish partnerships with dental professionals to conduct regular oral health check-ups and provide specialized care when needed. Dental professionals can offer valuable insights, guidance and training to nursing home staff.

Accessible dental supplies

Ensure easy access to dental supplies, including soft toothbrushes, fluoride toothpaste and mouthwash. Maintain an adequate supply of these items to facilitate regular toothbrushing and oral care practices.

Promotion of resident independence

Encourage and support residents in maintaining their independence in oral care routines to the extent possible. Provide assistance as needed but empower residents to take an active role in their own oral hygiene.

By incorporating these practical approaches, nursing homes can enhance their oral care systems, promoting better resident outcomes and reducing the risk of hospital-acquired pneumonia and other oral health-related complications.

Renee Kinder, MS, CCC-SLP, RAC-CT, serves as the Executive Vice President of Clinical Services for Broad River Rehab. Additionally, she contributes her expertise as a member of the American Speech Language Hearing Association’s (ASHA) Healthcare and Economics Committee, the University of Kentucky College of Medicine community faculty, and an advisor to the American Medical Association’s (AMA) Current Procedural Terminology CPT® Editorial Panel, and a member of the AMA Digital Medicine Payment Advisory Group. For further inquiries, she can be contacted here.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

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