Oral health: something to smile about!

Oral health is integrally linked to overall well-being. This article describes a research program focused on the contribution of poor oral health to systemic illness. Initial investigations examined factors related to streptococcal virulence that were important in dental caries and endocarditis and led to development of immunization strategies in animal models to reduce risk of endocarditis. Clinical investigations related to critically ill adults began with descriptive and observational studies that established the importance of dental plaque in development of ventilator-associated pneumonia (VAP) and examined existing nursing practices in oral care. Subsequent intervention studies sponsored by the National Institutes of Health (NIH) to test oral care protocols in critically ill adults have built on that foundation. The group's first NIH-funded randomized clinical trial tested the effects of toothbrushing and use of chlorhexidine in reducing risk of VAP in critically ill adults and showed that VAP was reduced by topical application of chlorhexidine initiated after intubation, although toothbrushing did not reduce VAP. The study had a rapid and dramatic effect on clinical practice. Results of the study were published in September 2009 in the American Journal of Critical Care, and in May 2010, the Institute for Health-care Improvement updated the recommendations for the care of patients receiving mechanical ventilation (the ventilator bundle) to include daily oral care with chlorhexidine, referencing the results of that study as evidence for the change. Chlorhexidine is now the standard of care for adults receiving mechanical ventilation. Because the effects of chlorhexidine after intubation were so beneficial, a second recently completed NIH-funded randomized clinical trial investigated the impact of chlorhexidine applied before intubation compared with after intubation. Currently a large randomized clinical trial is being launched to determine the optimal frequency of toothbrushing for critically ill patients receiving mechanical ventilation in an effort to maximize oral health benefits while minimizing systemic risks. The importance of collaboration and mentoring in building nursing science is discussed. Future directions for research also are explored.