Oral infection control in hospitalized patients: one directed at intensivists and cardiologists approach

Oral infection control in hospitalized patients: an approach to cardiologist and intensive care units doctors

Sergio Kahn; Elen Mangialardo of Savoy; Carlos Henrique Garcia, Fatima Maria Namen, John Junior Galan; Walter Augusto Soares Machado Veiga de Almeida University. Ibituruna Street 108, Tijuca. 20271-020 Rio de Janeiro RJ. skahn@openlink.com.br

ABSTRACT The aim of this study was to determine the degree of medical knowledge of periodontal medicine and check for any infection control protocol of the oral cavity in patients admitted to hospitals. To this end, 110 cardiologists and intensivists crowded in five hospitals in the city of Rio de Janeiro were interviewed. Among the subjects, 75.4% reported having knowledge about the term periodontal medicine, yet only 30% reported ever having read anything about it. Only 2.7% of physicians have the habit of collecting information on the dental history of the patients and 58.2% stated that this conduct is conditional on the state of the patient. Based on the data obtained, it can be concluded that knowledge of periodontal medicine and hence the importance of the control of oral biofilms in maintaining systemic health, it presents little spread between the medical profession. There was no industry or person responsible for oral infection control within hospitals evaluated and, consequently, the absence of any protocol, effective or not, oral infection control these units. Keywords: Control of oral infection, periodontal disease, systemic disease, cardiovascular disease

ABSTRACT This paper AIMS to find the current level of periodontal med-care knowledge, as well as the possible existence of some oral infection control protocol Regarding hospitalized

patients. Our sample gathered 110 cardiologists and intensive care units from medical doctors selected teams of five Rio de Janeiro hospitals. Preliminary numbers: 75.4% said to have heard something about Periodontal Medicine, although only 30% out of this group to have read something Admitted Concerning such subject. On the other side, only 2.7% of the sample informed to the consistent information searching along pacientes Their history, while 58.2% out of this group Admitted such conditional procedure to the patient's general state at the moment due. Through such numbers, we trend to come up to the Conclusion que, be it either through direct or indirect Periodontal Medicine technical information (and consequently with regards to the absolut Importance of preservation and control of oral biofilm and its impact on one's systemic health), the matter has been dimly spread among medical groups. Also the search revealed the probability Rio de que January hospitals lack either units or agents designed for prevention and control of oral infection, consequently, of such organizations not have any kind of protocols, reliable or not, concern to oral infections. Key words: Infection control protocol, Periodontal disease, Systemic diseases, Cardiovascular disease

Introduction
The distinction between medicine and dentistry dates back to the mid-nineteenth century, when the founding of the first dental school in the world, in Baltimore. Centennial year absence caused a huge loss in the emphasis of the impact of systemic disease on oral cavity and, more importantly, the impact of oral disease on systemic condition of the body. However, the breakthrough of dentistry and medicine in search of a better understanding of human pathophysiology enabled a more holistic and humane scientific behavior, in which the specialties again converge toward a common goal: to restore and maintain the health of the individual . Dentistry has evolved and directed his studies in pursuit of a greater understanding of periodontal disease in order to scale the influence and interaction of oral bacteria in imbalances and disorders of systemic health. For over a decade, studies interested in the presence and influence of bacteria of the oral flora in various tissue media have demonstrated a strong association between these pathogens and infectious distance tables. Some authors report that oral diseases may play an important role in the pathogenesis of various systemic diseases such as coronary heart disease, stroke, bacterial endocarditis, diabetes mellitus, respiratory infections. Among oral diseases, there is periodontal disease, wherein the presence of gram-negative microorganisms similar to those of many chronic infections and respiratory infections occurs in many cases 1-3 . Others like Offenbacher et al. 4 showed that infections by periodontal pathogens represent a significant risk factor for premature and low birth weight (PLBW) birth, estimating that 18.2% of PLBW be assigned to pregnant women with periodontal disease. Numerous scientific studies have demonstrated the strong relationship between this disease in the oral biofilm and course of respiratory infections, particularly pneumonia aspiration,

this being the most common type of nosocomial pneumonia and, as such, a serious cause of morbidity and mortality among inpatients 5.6 . Some clinicians have observed that cardiovascular and periodontal diseases, both chronic and multifactorial, have in common a genetic basis for susceptibility and also important components, such as those related to diet habits, hygiene and the practice of smoking, among others. Those relevant to the pathogenesis of caries and periodontal disease, as well as cardiovascular disease components. Therefore, according to Beck . et al 7 , both diseases have a number of characteristics in common, occur more frequently in older people, males, low socioeconomic and cultural level, smokers, diabetics with frameworks of stress and emotional genetic predisposition. The issue addressed in this work is delegated importance to oral infection control in hospitalized patients.Evidence of the work Yoneyama et al . 8 , Adachi et al . 9 and Fourrier et al . 10th have shown that the oral infection control in hospitalized patients reduced the number of nosocomial infections such as, for example, cases of aspiration pneumonia and cardiac complications. De Riso et al . 11 tested oropharyngeal decontamination using chlorhexidine gluconate 0.12% in patients who would be undergoing surgical procedures, obtaining very good results in reducing the rate of nosocomial infection in 65%. Based on the literature grounding us for a preventive action to nosocomial infections and health problems through chemical and mechanical control of the oral microbiota of hospitalized and unable to accomplish it autonomously patients, we sought to assess the scientific knowledge of critical care physicians and cardiologists on the importance of these procedures, but also verify the existence of protocols for such purpose in five hospitals located in the city of Rio de Janeiro.

Objectives
This study aimed to evaluate quantitatively and qualitatively the knowledge and practice of oral infection control study in patients admitted to hospitals located in the city of Rio de Janeiro through directed at doctors working in intensive and coronary care units approach.

Methods
110 cardiologists and intensivists crowded were evaluated in five hospitals (two local, one state, one federal and one private) located in the city of Rio de Janeiro centers possessing intensive care and coronary care units in full swing. Among the 110 subjects, there were 52 (47.2%) cardiologists, 26 (23.6%) intensivists and 32 (29.1%) respondents had the two specialties, intensive care and cardiology. Medical professionals cardiologists and intensivists in crowded selected for this study were evaluated from hospitals who agreed to cooperate freely with the same after reading and signing an informed consent. To collect data, a questionnaire containing 24 questions mixed, which was duly replied on interviews with study subjects was developed. The collected data were analyzed and interpreted in accordance with the technical standards dictated by the Brazilian Institute of

Geography and Statistics (IBGE) and presented in tables and graphs. The chi-squared ( was used 2 ) to verify the statistical significance at p <0.05. This research was submitted to the Ethics and Research (CER) of Veiga de Almeida University as well as their zip code of each hospital participating in the study.

Results
Faced with a general approach, as illustrated in Figure 1 , among the 110 physicians surveyed, 63 (57.3%) believe there is a relationship between oral disease and coronary artery disease, 96 (87.3%) claim to be a possible causal relationship between pneumonia and oral diseases, 48 (43.6%) find a positive association between past and diabetes mellitus, 26 (23.6%) respond positively to the relationship of oral infections and frames of stroke, and 24 (21.8 %) believe that oral pathogens can interfere with premature and low birth weight (PLBW) birth.

In the questionnaire relating to the collection of information on dental history (HO) during the interview, of the 110 respondents, only three (2.7%) reported having a habit of collecting this data, 64 (58.2%) recognized that this is an attitude probation and 43 (39.1%) responded that within the past medical history (HPP), data on the HO are not listed. Among the leading causes cited as a condition for collecting information on the HO, we can observe: patients with valvular disease or those who will undergo surgery to exchange valve prosthesis; cases or suspected endocarditis changes in the oral cavity, such as the presence of decayed teeth, presence of poorly fitting dentures and the presence of periodontal disease, when the patient's specific complaint relates to the oral cavity. Of the 110 physicians who participated in the study, 99 (90.0%) proved to have the habit of asking the opinion of other health professionals in the diagnosis and treatment plan of the diseases that affect their patients. 24 health professionals medical specialties and / or were cited. The general and vascular surgeons (50.50% - 50) appeared as the professionals most requested by cardiologists and intensivists, followed by neurologists (35.40% - 35), dentists (27.30% - 27), infectious disease (24, 20% - 24), nephrologists (22,20% - 22), lung (20.20% - 20), physiotherapists and clinical (16.20% - 16). When asked about the examination of the oral cavity, among all 110, fourteen (12.7%) said they do not have the habit of taking the oral cavity, 41 (37.3%) responded that they routinely examine the oral cavity of their patients and 55 (50.0%) stated that this is a conditional attitude to any observation in the clinical history. There was no statistically significant difference among doctors according to the hospitals (p> 0.05). The Figure 2 shows the percentage distribution of the most significant causes or situations cited by the doctors that would justify the examination of the oral cavity of patients. Among the 55 (100.0%) physicians stated that this is a conditional conduct, seventeen (29.3%) reported that changes in the oral cavity, such as poor dental conservation, use of handicapped aids, presence of periodontal disease, presence of bleeding, would indicate the need to conduct the examination of the oral cavity of the sick, twelve (20.70%) mentioned that they perform this test in the presence of patients with valvular diseases; eleven (19.00%), in frames or suspected endocarditis, eleven (19.00%) reported performing this procedure only when the patient complaint relates to the oral cavity, eight (13.80%) responded that they need to check when the hydration of patients, the approach of the oral cavity is performed and eight others also (13.80%) examine the oral cavity when the patient needs ventilation support.

When asked whether patients undergoing surgical procedures undergo a preliminary oral inspection of the 110 subjects, 23 (20.9%) responded that they do not conduct the oral examination in the preoperative and 75 (68.2%) stated that the oral cavity is inspected before patients undergo surgery. There were no statistically significant differences among hospitals (p> 0.05). The Figure 3 illustrates the percentage distribution of physicians according to the purpose of intra-oral inspection among those who reported performing the clinical examination of the oral cavity before surgery. Among these, 75 (60.00%) look for decayed teeth, 78.9% are concerned about the presence of abscesses or gum disease; 64.40%, with the presence of prostheses; 43.30% seek if there evidence of injury and 12.20% say that this is a routine preoperative for valve surgery.

Among those who denied performing oral examination prior to surgical procedures (23 subjects = 20.90%), we sought to know the reasons that justify not performing this inspection. Only 22 individuals responded to this question. The reasons or circumstances that would justify such conduct cited were lack of habit or forgetfulness, lack of preparation and sectorization of the practice area of occupational health and difficulties in conducting oral examination on their patients because often they are carrying tube orotracheal. Regarding medical knowledge about the existence of a specific protocol for maintaining hygiene and oral infection control in hospitalized patients in the ICU and UC showed the following results, all physicians responded to this question, among these, 42 (38.2 %) state a specific protocol for this purpose, 60 (54.5%) responded that there is no standardization exists for this procedure-eight (7.3%) reported not know how to answer this question (p> 0.05); A question related to methods of monitoring oral flora used in the hospital, where 79.40% of physicians stated that the mouthwash was used for this purpose; 53.30% reported

cleaning the cavity with gauze and 38, 30% reported that brushing was also used for this purpose. There was no statistically significant difference between the hospitals (p> 0.05); Cetilpriridnio chloride (Cepacol ) was the most cited by the medical substance from the oral rinses used as a solution in oral hygiene procedures (76.40%). The solution of chlorhexidine gluconate (Periogard ) accounted for 32.70% of the responses and Biotene (solution containing lactoferrin, lysozyme and lactoperoxidase) was cited as the solution of choice by 17,30% of physicians. About medical knowledge about the prescribed dose in CTI and UC for the substances mentioned above, 38.0% of physicians reported using the solution once a day, 18.20% of them mentioned that the substance use every twelve hours; 10.0% three times a day, 8.2% four times daily and 23.6% of subjects reported not knowing the dosage used in the ICU or UC. Was asked how it was made the prevention of secondary infections in hospitalized and intubated patients unable to perform the practice and methods of control and plate autonomously. Among the 110 physicians, 71 (64.5%) reported being through gauze soaked in a mouthrinse, procedure performed by nurses; fifteen (13.6%) only cited using mouthwash for this purpose: eleven (10% ) stated that through daily oral hygiene, nine (8.2%) reported being through the aspiration of secretions from the oral cavity; seventeen (15.5%) using aseptic conduct high headboard and gastric protection, four (3.6 %) reported that the procedures are performed by the nursing industry, but who are unaware of exactly what is done, one (0.9%) said that their hospital had no routine for this purpose; another individual (0.9%) stated that these procedures are not performed due to other priorities and three (2.7%) reported not having this information. When asked how health professionals can help their patients in controlling infection of oral cavity 62 (56.4%) subjects reported believing that the orientation of patients regarding eating habits and oral hygiene is the best way to achieve this goal; Sixteen (14.5%) stated that the guidance of health professionals, nurses and medical staff would be a good way to go, eight (7.3%) state that through standardization and training can achieve good results; 32 (29.1%) believe that referral to specific professional would be a way to help their patients in controlling infection of the oral cavity.

Discussion
Periodontal disease is a multifactorial infectious bacterial condition of an inflammatory nature, in which the plaque is the initiating factor for the disease and the accumulation of biofilm destroys the supporting tissues of the tooth. There are many epidemiological studies have suggested that oral infections, especially periodontal disease may be a risk factor for systemic diseases. Although 83 (75.4%) of respondents report to have heard about the term periodontal medicine, only 33 (30.0%) reported having read something about it. In general, 57.30% responded positively to the relationship between oral and cardiovascular diseases and 87.30%, respiratory infections. However, only 23.60% recognize that periodontal pathogens can influence the course of diabetes mellitus, and 78.20% are unaware or do not agree that pregnant women with periodontal disease may generate premature and low birth weight fetuses.

Salivary secretion plays a dynamic role in maintaining oral health and when suppressed or diminished because dry mouth, difficulty swallowing the bolus and increased risk of developing opportunistic infections. Amerongem et al.12 mentioning that the presence of fluid in salivary immunoglobulin and antimicrobial enzymes, such as lactoferrin, lysozyme and lactoperoxidase, among others, is of fundamental importance for the defense of the body and health maintenance. In many cases, sedated and hospitalized in intensive care units patients have low salivary secretion within two weeks and show changes in oral microbial flora, favoring the prevalence of gram-negative bacteria and thus allowing frames of pulmonary aspiration of such infections pathogens. Among those who cited the need for ventilatory support as a justification to the clinical examination of the oral cavity, said do it to verify the anatomic, prosthetic or dental conditions that could derail the passage of the endotracheal tube, however, studies show that pneumonia is nosocomial infection most common within intensive care units, contributing significantly to the morbidity and mortality in these centers. According Limeback 13 , nosocomial pneumonia accounts for 10-15% of all infections acquired in hospitals, especially in intensive care units (ICU) and 20 to 50% of patients who contract it die. Ventilation equipment become contaminated by bacteria themselves and patients appear to be a significant risk factor in the etiology of this disease. Among individuals who reported not perform a preoperative examination of the oral cavity of patients undergoing surgical procedures, some (13.60%) mentioned the difficulty of carrying out the inspection of the oral cavity due to the presence of pulmonary ventilation tube as a justification for such negligence. The valvular diseases and include endocarditis were also cited by the doctors interviewed quite as relevant to the clinical examination of the oral cavity. When doctors refer to include endocarditis and patients with valvular diseases, these proved to be abreast of the literature on the possible consequences of a subsequent surgical procedures transient bacteremia and on considerations of the American Heart Association (AHA) regarding of preventive measures against risk of endocarditis. Infective endocarditis is caused by infection of endothelial tissue of the heart, resulting from microbial colonization of the damaged natural or prosthetic heart valves. Mask14 mentions that the dental patient with valvular disease presents certain challenges and risks include hemodynamic instability, cardiac arrhythmia, and endocarditis. Currently, many oral hygiene products and control of microbial flora are available in the market and it is for health professionals and those responsible for acquiring them seek information within the broad literature on efficacy, dosage and mainly indicated. Although many studies clearly demonstrate the efficacy of chlorhexidine digluconate in chemical control of dental biofilm, only the private hospital has a fairly significant percentage in the use of this solution, although in the federal unit, 38.50% of its representatives have cited chlorhexidine. In other hospitals, the results showed predominant values for cetylpyridinium chloride. Before a general framework, the most widely used drug of choice is not in accordance with current literature. Cetylpyridinium chloride when used orally rapidly binds to the tooth surface and the plaque, however, comes off easily losing its effect. Only 27.3% of physicians have the habit of asking the opinion of dentists and only 11.80% of professionals said they had received training to assess the oral condition of their patients and thus to interpret the oral findings in the clinical history, clearly denoting lack of interdisciplinarity between medical and dental classes, a fact fundamental to the growth and improvement of health care services.

Want to optimization of health services, due to a reduction of the risk and incidence of secondary nosocomial infections and improves the prognosis of patients, reduction of morbidity and mortality in intensive care and coronary care units and reducing the time and hospitalization costs, enabling, in this way, beds, budget and consequently suppressed assistance to the population demand. These observations emphasize the need for early initiation of preventive programs, these targeted not only to population masses, but mainly at-risk populations and the various professional health programs. The hyper does not allow the perception of global, as well as the essential, splintering into pieces which could be contextual. The best would be a holistic approach to human being, provided by the exchange of information and the understanding between the specialties. The human being needs to be addressed as a whole, where their health can not be separated into areas.

Employees
S Kahn and WAS Machado participated in the theoretical conception and design of research; Mangialardo ES performed the data collection, data evaluation and writing; CH Garcia participated in the drafting and graphic part, Galan J Namen Junior and FM contributed to the drafting and review of data.

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Article submitted on 20/10/2007 Approved on 07/05/2008