Procedure

Usually, oral condition is neither contraindicative nor determinant for the surgery. However, as we will see in this paper, the oral cavity should not be neglected in surgery even if intervention is expected to take place in other cavities, such as the abdomen or thoracic organs. Mouth is the first part of the alimentary canal that meets food. Further, the oral cavity is lined with the mucus membrane. The teeth are structures within the mouth found the jaws. The teeth are attached in a complex covering called periodontium. Anatomical conditions determine the spectrum of hygiene patterns essential for peri-operative care.

The mucus membranes of the mouth may undergo numerous pathologies, including xerostomia (dry mouth), ulcers and bacterial inflammation (Yasny & Herlich, 2012). In the oral cavity, the teeth are of a special concern since the tooth plaque contains a substantial amount of bacteria (El-Solh et al., 2004). Patients exhibiting poor oral hygiene are at increased risk of complications associated with surgery. Those patients whose oral cavity has been neglected before surgery comprise a group of increased risk for numerous short and long-term complications (Yasny & Herlich, 2012). Therefore, there is a strong correlation between the oral health and general condition.

Individuals with poor dental conditions undergoing surgery are at the higher risk for infectious complications (Yasny & Herlich, 2012). Patients presenting for surgery who have not had a dental examination for years may be harboring an undetected oral infection that can significantly compromise surgical outcome–even before it commences.

During pre-operative evaluation, a thorough oral cavity examination is needed. However, some authorities suggest there are a little data in order to prove the effectiveness of infective endocarditis prophylaxis (Taib & Penny, 2010). They state that transient bacteriemia occurs even when chewing or brushing teeth, thus the heart is exposed to infective risks every day, but only a minority develops postoperative infective endocarditis. Taib and Penny (2010) discuss the possibility of inoculating organisms from daily activities rather than dental procedures themselves.

In this paper, we review the evidence for oral peri-operative hygiene aiming to reduce the risks of associated complications to minimum.

Basis for Practice

Patients with very poor oral hygiene are at the higher risk to compromise, otherwise satisfactory surgical outcome. Further, unstable teeth may be aspirated or ingested into the stomach during anaesthesiological manipulations (Yasny & Herlich, 2012). Notable redness, swelling, purulent excretions are of special concern since these findings strongly suggest high risk of peri-operative bacterial or fungal contamination (Yasny, 2009).

Peri-operative dental damage is one of the most unpleasant anesthesia-associated morbidities. The incidence of peri-operative dental damage may be as high as 12%, nearly a half of them occurring during endotracheal intubation (Yasny, 2009). According to Yasny & Herlich (2012), periodontically involved and decayed teeth are easily damaged during the slightest manipulations (endotracheal intubation through the mouth, nasogastric tube placement, oral suction). Pressure is necessarily applied to the oral structures during certain anesthesiological manipulations, thus leading to unreasonable damage of the diseased teeth. Especially, this is true when some difficulties during such manipulations occur. For example, difficult intubation when anatomy is challenging or emergency surgery (Mallampati).

Critically ill patients in their dental plaques have both Gram-positive and Gram-negative bacteria, including Pseudomonas aeruginosa (El-Solh et al., 2004). There is a close a relationship between the oral condition and ventilator-assisted pneumonia, and standard antibiotic regimen does not replace mechanical removal of dental plaques (Akutsu & Matsubara, 2009). The contributors state that when a patient has pathogenic flora in his dental plaque, the risk of postoperative pneumonia is higher after an esophagectomy.

Chlorhexidine oral rinse reduced the risk of pneumonia in cardiac surgical patients (American Association of Critical Care Nurses, 2007). In the postoperative period after esophagectomy, brushing teeth 5 times a day reduced the risk of post-operative pneumonia from 32% to 9% (Akutsu & Matsubara, 2009). Furthermore, a systematic search is under assessment at this time in order to reveal whether standardized peri-operative oral hygiene improves respiratory tract infections after thoracic surgery or not. In this study, a compare between mechanical oral cleaning (brushing teeth) and mouthwash with an antiseptic is to be performed (Pedersen et al., 2012). Thus, the results of this survey will be published at the end of 2013.

Usually, peri-operative oral cavity care is the attending physician’s responsibility in cooperation with the anesthesiologist. The nurse may also perform inspection and carry out history taking in this particular topic.

Rationale

The first reports suggesting relationship between the oral cavity and general state of health date back to the 19th century (Yasny & Herlich, 2012). During the recent decades, this connection is under intensive study. The theory states that dental plaques provide an environment for microorganisms. As soon as the mucus membranes or the gum is damaged, the bacteria may colonize any other part of the body (Taib & Penny, 2010; Yasny & Herlich, 2012).

Endothelium lining the inner surface of the heart is prone to bacterial colonization, especially when there is a concomitant factor (congenital heart lesion, valvular prosthesis, residual defects after previous surgery). Bacteria from the bloodstream colonize the initial deposition of platelets and fibrin (Taib & Penny, 2010). The propensity to adhere to the non-bacterial detritus within the endocardium is dependent on the type of bacteria. The most common source for bacterial invasion is the oral cavity. Moreover, it is reported that more than two thirds of bacterial endocarditis result from Gram-positive bacterial flora originating from the oral cavity. Thus, Taib & Penny (2010) state species that most commonly affect the heart belong to the normal oral cavity flora such as Streptococcus of the Viridans group, Streptococcus sanguis, Streptococcus oralis (also known as mitis), Streptococcus salivarius, Streptococcus mutans, and Gemella morbillorum.

Explanation

Pre-operative oral status evaluation and subsequent management may prevent numerous side effects in non-dentistry surgery. The management options also include mucus membranes visualization, teeth examination, dentist consultation if needed and careful peri-operative manipulations. The procedure of oral health control in the peri-operative period is not performed routinely in this hospital. Usually, this is the anesthesiologist’s preference to take care of the mouth before the operation. Furthermore, anesthesiologist’s nurse and anesthesiologist are engaged in performing procedures during the operation (intubation, nasogastric tube placement, prosthesis replacement. etc.). In the post-operative period, this is the duty of the nurses in the intensive care unit/post-operative ward to support oral hygiene. In general, peri-operative oral care protocol does not exist as a complete recommendation, thus leaving space for potentially dangerous misses.

Reference List

Literature on peri-operative oral cavity management is dedicated mainly to the infective endocarditis prevention strategy. There have been numerous guidelines published over the five decades within all nations. Some approaches differ among them, but the key ideas remain unchanged suggesting the importance of oral hygiene, especially in those with structural heart diseases. The literature reviewing other peri-operative oral challenges is smaller. Some published manuscripts are listed below.

Clinical Implication

Adequate oral cavity management in the peri-operative period adds to patient’s safety and comfort. Pre-operative teeth brushing and antiseptic washing evacuates a substantial number of pathogens from the dental plaques making the oral cavity less hazardous to systemic bacterial colonization. Healthy oral condition or at least controlled status of the unstable teeth would prevent aspiration effectively. A clear understanding of how fragile the teeth are prevented the medical staff from over-aggressive intubation and suction manipulation. Understanding of the dental microflora variation helps choose the antibiotic for peri-operative prophylaxis more effectively. A dental-associated infection should occur, moreover the thorough knowledge of the microbiological pattern helps to decide which antibiotic is more appropriate for the initial medical treatment (Taib & Penny, 2010).

Procedural Changes and Stakeholder

In spite of the fact that missed poor oral cavity conditions may potentially complicate the peri-operative course, there are no full management guidelines. In order to cover the issue completely, one has to apply versatile options concerning various pathologies and disorders of the mouth. Usually, routine oral cavity inspection is considered before surgery (Eduardo et al., 2010). The study held by Eduardo et al. (2010) suggests 100% of that undergoing bone marrow transplantation undergo a thorough oral cavity evaluation. In the process of diagnostics, there is a need in a dentist; moreover, dentistry is performed before transplantation. Furthermore, all of the 12 studied centers report special mouth washing antiseptics developed for proper use in hygiene in the peri-operative period. These findings probably account to the fact that transplantation patients are especially vulnerable to bacterial hazards. Nevertheless, we suggest the strategy of total dental coverage to be applied to all surgical patients.

Pre-operative evaluation must include recognition of prosthesis, crowns and implants. In addition, soft tissues need to be examined in detail. Further, troubles with swelling should be kept in mind. Usually, it is not difficult to evaluate the surface of the teeth in order to appreciate their condition. Attention is paid to lose teeth because their instability may cause aspiration and undesired management difficulties. Loose teeth must be insecure. Pre-operative discussion with the patient about his oral condition is also recommended since this would reduce unexpected postoperative disputes or conflicts. On the other hand, careful mouth handling, easy suctioning, prudent intubation/extubation manipulations are expected to reduce the risk of dental damage.

Adequate dose of antibiotic is used in order to prevent infective endocarditis. Thus, this part of the management is probably best studied and described in detail (Wilson et al., 2007).

In order to apply these suggestions into everyday practice there will be conducted seminars explaining the role of oral hygiene for the surgical patients. Further, it should be noted that all medical staff must be engaged in the process of oral hygiene compliance. In order to achieve this goal, an institutional policy should be changed towards a stricter and controlled guideline.

Translation of Research

In addition, it should be noted that all researches ever conducted undergo a selection protocol. This means that no matter how carefully a trial or research was planned, it would always engage those patients who were subjected to the investigation. Furthermore, the cohort is usually picked up according to a strict protocol. In real life, however, the patients may differ from those of the cohorts of the trials. It means that results of studies should be analyzed with care and critically enough so that hasty decisions do not put the patient’s safety at risk. This is the reason why medical societies organize their work out of guidelines concerning a particular field of health care.

Barriers

Nurses might meet barriers when implicating the recommendations in practice. At first glance, the tooth brushing and tooth washing procedures are at their superintendence, and this is probably the strongest part of the management strategy. Because in assisting the procedures, the nursing staff is the first to meet the dental disorders. However, lack of experience in dentistry might preclude from fast and accurate diagnostics of the problem. In the case of a suspicious situation, a professional dentist is in a need and the medical institution should supply the surgical department with a dentist or an appropriate consultant. Therefore, this may lead to the financial burden and might be an obstacle. On the other hand, in the hierarchy of the medical community the nurses negotiate with the attending physicians, which mean the final decisions made by them.

Strategies

Usually, nurses spend much more time with the patients that physicians, suggesting they may be better acquainted with the dental situation in a particular individual. Compliance between patients and relatives (or parents in the pediatric population) and nurses suggests a potential for improving peri-operative oral cavity management. This is much easier for a nurse who would spend more time communicating with a teenager in order to persuade him or her to do mouth washing properly, than had it been conducted by a physician who is distressed by the surgery itself. In geriatric patients, the nurse is essential to assist in many interventions, including dental management. The nurse will be the first to meet the needs of the patient and learn how to overcome them.

Because nurses communicate with the patients first-hand, their information is unaffected by surrounding stressful conditions. The institutional policy should encourage physicians’ professional communication with the nurses as soon as they may provide with accurate and unprejudiced information about the individual. The willingness of the surgical team to work as a team and the readiness of the surgeon to consider favorably recommendations from nurse may result in improving the patient care. It would be also favorable for the team to organize a meeting with reports concerning updated knowledge on the peri-operative interventions, thereby educating and self-educating.

A potential strategy to overcome the disordered status of peri-operative oral care protocol is to insist on attending physician’s responsibility in order to control the whole process. The attending physician may deliver some procedures (as well as responsibilities) to the nursing personnel. For example, the nurse may take care of implants or control oral hygiene on the post-operative period. The nurse may also inspect the oral cavity pre-operatively to find gross abnormalities.

Another potentially helpful strategy is a survey. Supposing, the duty nurse is obliged to deliver an oral health condition questionnaire to the patient (or close relatives if the individual is disabled or unconscious). The list of questions would consist of some key points:

A. Oral history: 1) when attended the dentist for the last time;

                       2) what was done at that time.

B. Current status: 1) complaints if any;

                          2) implants if any, the number, type of care, etc.

C. Personal oral hygiene regimen (regularity, completeness, etc.)

If the patient or relatives cannot fill in the form, the nurse may perform inspections and necessary discussions to complete the evaluation.

Application of Findings

The findings of this manuscript establish the borders for the surgical team’s incompetence in the field of oral hygiene. The knowledge from this study makes nurses more adequate when managing all surgical patients. This adds to their professionalism and training abilities. Furthermore, any individual who undergoes a surgical procedure no matter what kind of must have his mouth inspected. The mucus membranes should be intact, any major damages, especially lesions changes and gum injuries suspect increased risk of infectious complications. Oral mucositis can be treated actively by laser technologies (Eduardo et al., 2011). Dentistry history taken, the teeth are visualized. Further, any foreign bodies and implants need to be noted and explained. Search for decayed and poor teeth is conducted and in the case found, a discussion with the attending physician is advised. Tooth brushing before the surgery does not substitute tooth washing because dental plaques containing bacteria are rather stable. The same refers to postoperative care. However, institutional polices for tooth washing should be also respected since evidence for benefits is lacking. Prophylactic antibiotics in the peri-operative period are put into the consideration regarding oral situation. Patients with structural heart anomalies experience a more strict prophylaxis regimen according to their heart diagnosis as states the American Heart Association Recommendation (2007). The latter is a subject for discussion with the physicians.

In conclusion, I would like to cite from excellent review by Yasny and Herlich (2012):

The hidden hazards of dental and oral infections can usually be easily detected with a routine preoperative dental evaluation. If not treated preoperatively, an infection of dental origin can significantly compromise surgical outcomes in terms of treatment and finances. In the preoperative period, it may be a primary care physician, nurse, anesthesiologist, or other healthcare provider who is the first caregiver to look inside a patient’s mouth in years.

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