Oral Health in Healthcare Settings to Prevent Pneumonia Toolkit

Leadership support of good oral care strategies is necessary for teams to secure the time and resources to implement changes and engage patients and families in prevention efforts.¹⁴ Important factors for success also include having a clear and comprehensive prevention plan and ongoing education and training for staff. Regular monitoring and evaluation of prevention efforts is necessary to track data and identify new opportunities for improvement.¹⁵ Sharing best practices and success stories can help promote the wider adoption of prevention strategies.

Engage Leadership Support

• Demonstrate the value of pneumonia prevention efforts which can lead to positive patient health outcomes. Examples include:
  • John Medical Center in Bixby, Oklahoma, implemented a structured oral care protocol as part of an NV-HAP prevention study. During the first year of implementation (2010), they prevented 5 cases of pneumonia, saving the organization $195,4000.¹⁶
  • The Department of Veterans Affairs Medical Center in Salem, VA conducted an oral care pilot program in 2016; they reduced NV-HAP rates by 92% and saved an estimated $2.84 million dollars and 13 lives during a 19-month period.¹³
  • Orlando Regional Medical Center in Florida implemented an enhanced oral care protocol; they reduced NV-HAP rates by 85% in their medical unit and by 56% in their surgical unit over a 12-month period (2018–2019).¹⁷
• Establish a multi-disciplinary team to address NV-HAP, including (but not limited to) representation from applicable departments: ^9,14
  • Clinical education
  • Dental team
  • Infection prevention
  • Medicine and laboratory services
  • Nursing
  • Nutrition
  • Occupational health
  • Patient and family support
  • Pharmacy
  • Physical therapy
  • Respiratory therapy
  • Speech pathology
  • Quality improvement leader
• Have regular team meetings with NV-HAP prevention team to:
  • Review data
  • Identify new opportunities for improvement
  • Develop improvement plans
  • Develop new protocols or policies

Train Staff

• Staff need to clearly understand how NV-HAP can develop and which patients are at highest risk.
• Train staff on new processes, protocols, and how to safely and effectively use new supplies or equipment.
• Identify any gaps in skills and knowledge through:
  • Patient risk assessment results.
  • Results of quality improvement studies and root-cause analysis findings from a review of NV-HAP cases.
  • Feedback from frontline staff who manage the care of patients at risk for pneumonia.
• Consider using a standardized training program such as the U.S. Department of Veterans Affairs Oral Care Training for Nurses and Nursing Assistants [PDF – 24 Pages].
• Consider using a staff safety assessment such as the Agency for Healthcare Research and Quality (AHRQ) Staff Safety Assessment- CUSP Toolkit.
  • Describe potential risk for the next patient in your unit or clinical area (e.g., develop NV-HAP).
  • Describe what you think can be done to prevent or minimize this harm (prevent NV-HAP case from happening).

Completing an oral health assessment is a crucial step in developing an individualized care plan with an interdisciplinary team. During the oral health assessment, members of the care team can identify NV-HAP or other health risk factors, recognize special considerations, and physical limitations that may impact the patient’s ability to perform oral care, and determine the priorities and needs of the patient.

Upon Admission

• Complete oral health history
  • This should include oral hygiene beliefs, practices, and the current state of oral health to identify potential risk factors.
    • When was your last preventive dental visit (e.g., “cleaning” and exam)?
    • Do your gums bleed, or have you been diagnosed with periodontal disease?
    • Have you had dental decay in the last 12 months?
    • Do you have any dental pain?
    • Do you ever experience dry mouth?
    • How often do you brush your teeth?
    • Do you have a removable dental appliance (e.g., denture or partial denture)?
    • Did you bring oral health care supplies (e.g., toothbrush, toothpaste, mouth rinse)?
    • Do you have any prescription oral care products (e.g., toothpaste, mouth rinse, saliva substitutes)?
  • Review medications or past medical history such as radiation treatments to the head and neck that may cause dry mouth.
  • Include results of aspiration risk assessments.
  • Consider using or modifying existing oral health history forms such as the one found in the Registered Nursing Association of Ontario’s (RNAO) Oral Health: Supporting Adults Who Require Assistance, Appendix G.¹⁸
• Complete a physical oral assessment
  • Use a standardized, valid, and reliable oral health assessment tool. Examples include:
    • RNAO Oral Health: Supporting Adults Who Require Assistance, Appendix I
    • The Kayser-Jones Brief Oral Health Status Examination (BOHSE) [PDF – 2 Pages]
    • Oral Health Assessment Tool (OHAT) for Non-Dental Professionals [PDF – 9 Pages] (fig. 1)
    • Becks Oral Assessment Tool
• Determine a care plan to address oral health during hospital stay based on current risk factors.
• Provide high-quality oral health care supplies to patients (e.g., toothbrush, toothpaste, mouthwash, denture cleaning supplies), such as those with a professional seal of approval.
  • Soft toothbrush with a smaller head is generally preferred.
  • Toothpaste with fluoride is preferred for non-edentulous patients.
  • Non-foaming toothpaste is generally preferred for patients who are intubated or having difficulty swallowing.
  • Alcohol-free mouthwash is preferred, especially for patients who are experiencing dry mouth.

Documentation and Data Collection

• Develop written protocols and standard operating procedures (SOPs).
  • Ensure a protocol exists that addresses providing oral care to non-ventilated patients.
  • Specify supplies, procedures, and frequency of oral care.
  • Educate staff to ensure they are knowledgeable about and able to deliver appropriate oral care, and that they understand the link between oral microbes and pneumonia.
  • Post protocols in areas easily accessible to staff.
• Develop a plan to document care provided, which could include:
  • Type of products used for oral care.
  • Frequency of oral care.
  • Special modifications to oral health products.
  • Behavioral issues (lack of cooperation or refusal of care; difficulties performing oral hygiene).
• Use electronic health record (EHR) prompts to help ensure clear documentation.¹⁹
• Conduct audits of EHR documentation to monitor oral care delivery and identify barriers to providing and documenting oral care.

Sample Oral Care Procedures^{9, 12, 14, 17, 18}

For most patients, oral care should be provided at least 2 times daily, for example after a meal and before bed. Staff should supply all patients with basic oral care products which should include:

• Toothbrush with soft bristles
• Appropriate toothpaste (e.g., fluoride-containing, desensitizing, non-foaming)
• Alcohol-free antiseptic mouthwash
• Petroleum-free lip moisturizer
• Basin for the patient to spit into if unable to get to sink

Additional supplies may include:

• Suction toothbrush
• Dental floss or interdental cleaners
• Products to assist with dry mouth, as needed
• Prescription oral rinse per physician/dentist orders
• Denture cup, labeled with patient name
• Denture brush or soft toothbrush
• Soft toothbrush for gums, tongue, and inside of cheeks
• Disposable oral swabs
• ADA-approved denture cleanser
• Denture adhesive as needed for retention

Basic oral care procedures for self-care and staff-assist (i.e., patients who are able to expectorate, or spit out):

1. Set patient up at sink or in bed with all products.
2. Instruct patient to brush teeth for two minutes, spending 30 seconds in each quadrant of the mouth, and finish with brushing the tongue.
3. If the patient is able and supply is available, use floss or interdental cleaners.
4. Rinse with mouthwash, swishing for 20 to 30 seconds.
5. Moisturize the interior of the mouth and lips with saliva substitute products using a disposable oral swab, as needed.
6. Discard disposable items in an appropriate receptacle.
7. Label oral care supplies with patient’s name and store in a clean, dry location.

Procedures for patients dependent on staff for oral care (i.e., patients with known difficulty swallowing, not able to spit out, and at risk for aspiration or accidental entry of material into airway and lungs):

1. Obtain additional necessary equipment such as a suction toothbrush.
2. Sit the patient upright or in a side-lying position.
3. Inspect mouth and use suction to remove any excess saliva or loose debris.
4. Connect oral brush to suction.
5. Wet the toothbrush and apply toothpaste or oral rinse.
6. Brush teeth for two minutes, spending 30 seconds in each quadrant of the mouth; finish with brushing the tongue.
7. Use a suction brush to suction toothpaste, saliva, and debris.
8. Dip a disposable oral swab into mouthwash and swab along teeth, gums, cheeks, palate, and tongue.
9. Suction to remove excess rinse.
10. Moisturize mouth with saliva substitute product(s) and apply lip balm, as needed.
11. Discard disposable items in an appropriate receptacle.
12. Label oral care supplies with patient’s name and store them in a clean, dry location.

Procedures for removable appliance care for patients (full dentures, partial dentures, retainers, night guards, etc.):

1. Remove dental appliance after each meal.
2. Rinse under water to remove loose food debris.
3. After removing the dental appliance(s), place them in a labeled denture cup.
4. Fill the sink with water or line it with a washcloth to cushion the dentures in case they are dropped.
5. Carefully brush dental appliance(s) with warm tap water and denture brush or soft toothbrush. Do not use toothpaste as this may scratch the surface of the dentures and make them more susceptible to staining and collecting debris and plaque.
6. Use a separate toothbrush with water to brush the palate, buccal (cheek) surfaces, gums, and tongue.
   1. If toothbrushing oral tissues is painful, try using a finger wrapped in a clean, damp cloth or gauze.
7. Patient can swish and spit mouthwash, if able, or use oral swab to apply.
8. Moisture mouth with saliva substitute product(s) and apply lip balm, as needed.
9. Take removable dental appliance(s) out every night and soak in warm water with a denture cleanser to loosen plaque and tartar to prevent gingival irritation and possible candidiasis infections.
10. After soaking removable appliance(s) overnight, rinse the denture(s) as described above prior to patient inserting them into mouth.
11. If patient needs adhesive to hold removable appliance firmly in place, follow manufacturer directions.
12. Assist patient in inserting removable appliances into mouth as needed.
13. Label oral care supplies with patient’s name and store in a clean, dry location.

If the patient has redness, inflammation, ulcer(s), bleeding, candidiasis (thrush), or pain, especially where a dental appliance sits:

• Provide medical treatment in consultation with a dental professional.
• If an ulcer is present underneath a removable appliance, if possible, remove the appliance until the ulcer has healed.
• Warm saltwater rinses can be done several times a day.
• If redness and inflammation is present, ensure physical cleaning of the removable appliance is being completed and that the appliance is being removed at night and whenever else possible.

Special Patient Considerations

Special care considerations may arise when the patient cannot open their mouth, has a difficult time holding their head still or up off their chest, refuses oral care, or forgets to perform oral hygiene care.¹⁸ Modifications to a patient’s oral care plan may be needed to address these special considerations. Healthcare personnel should work with their team of medical and dental professionals to tailor a patient’s oral care plan to match their special considerations. Examples of modifications include:

• Assist the patient in bringing the toothbrush to their own mouth and brush the teeth together (hand over hand).
• Use different dental products such as adaptive toothbrushes, mouth rinses, spray bottles, suction toothbrushes, etc.
• Try providing oral care at another time of day when the patient is more cooperative or in a different environment that is more suitable.
• Ensure that oral care reminders are listed in the patient’s care plan.
• Enlist the assistance of another caregiver.

Before Hospitalization

• Encourage individuals to establish a dental home and complete a preventive dental visit to identify and eliminate any existing dental conditions or disease, if possible, prior to scheduled surgeries or hospitalizations.
  • At least one preventive dental visit within 3-years has demonstrated a reduction in the risk of ventilator-acquired pneumonia by as much as 22%.²⁰
  • Patients with moderate to severe periodontal disease may have a 2–5x higher risk of chronic respiratory disease.²¹

During Hospitalization

• Educate patients and their caregivers or advocates on the risks of developing pneumonia during hospital stays.
• Discuss methods to prevent NV-HAP including correct oral care procedures.
• Encourage patients to continue their oral care plan at home.
• Encourage patients to follow up with a dental provider after hospitalization to develop an ongoing oral care plan.

Patient and Caregiver Education Resources and Signage

• Mark AM. Oral health care tips for caregivers. J Am Dent Assoc. 2019 May;150(5):480. doi: 10.1016/j.adaj.2019.03.005. PMID: 31029215.
• S. Department of Health and Human Services. National Institutes of Health. National Institute of Dental and Craniofacial Research. Practical Oral Care for People with Developmental Disabilities. Available here: https://www.nidcr.nih.gov/sites/default/files/2017-09/dental-care-every-day-caregiver.pdf [PDF – 12 Pages].
• S. Department of Veterans Affairs, Brush Your Teeth to Prevent Pneumonia. Available here: https://www.va.gov/innovationecosystem/assets/documents/PneumoniaTeeth_Brochure_Feb2020.pdf [PDF – 2 Pages].  

The Association for Professionals in Infection Control and Epidemiology (APIC). Implementation Guide on Non-Ventilator Healthcare-Associated Pneumonia (NV-HAP).

The Joint Commission. Quick Safety. Preventing non-ventilator hospital-acquired pneumonia. Issue 61, September 2021. https://www.jointcommission.org/-/media/tjc/newsletters/quick-safety-61-nvha-pneumonia-final-9-3-21.pdf [PDF – 2 Pages]. Accessed April 19, 2023.

Klompas M, Branson R, Cawcutt K, Crist M, Eichenwald EC, Greene LR, Lee G, Maragakis LL, Powell K, Priebe GP, Speck K, Yokoe DS, Berenholtz SM. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol. 2022 Jun;43(6):687-713. doi: 10.1017/ice.2022.88. Epub 2022 May 20. PMID: 35589091.

Munro SC, Baker D, Giuliano KK, Sullivan SC, Haber J, Jones BE, Crist MB, Nelson RE, Carey E, Lounsbury O, Lucatorto M, Miller R, Pauley B, Klompas M. Nonventilator hospital-acquired pneumonia: A call to action. Infect Control Hosp Epidemiol. 2021 Aug;42(8):991-996. doi: 10.1017/ice.2021.239. Epub 2021 Jun 9. PMID: 34103108.

Quinn B, Giuliano KK, Baker D. Non-ventilator health care-associated pneumonia (NV-HAP): Best practices for prevention of NV-HAP. Am J Infect Control. 2020 May;48(5S):A23-A27. doi: 10.1016/j.ajic.2020.03.006. PMID: 32331561.

Registered Nurses’ Association of Ontario (RNAO). Oral health: Supporting adults who require assistance. 2nd ed. Toronto (ON): RNAO; 2020. https://rnao.ca/bpg/guidelines/oral-health-supporting-adults-who-require-assistance. Accessed April 24, 2023.

U.S. Department of Veterans Affairs. Office of Nursing Services (ONS). Healthcare Acquired Pneumonia Prevention by Engaging Nurses (HAPPEN). Available here: https://www.va.gov/NURSING/index.asp

• HAPPEN Guide (Non-VA) [PDF – 23 Pages]
• HAPPEN Oral Mouth Care Documentation Content Tool [PDF – 1 Page]
• NV-HAP Calculator (Non-VHA)
• Oral Care Documentation Audit Tool [PDF – 1 Page]
• Oral Care Patient Brochure [PDF – 2 Pages]
• Oral Care Training Slides [PDF – 24 Pages]
• Patient Oral Care Survey [PDF – 1 Page]

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