Oral Care as a Preventive Measure of VAP; Miswak Versus Chlorhexidine and Toothbrush.
Condition: Ventilator Associated Pneumonia
MeSH terms: Pneumonia, Ventilator-Associated
Study type: Interventional

Summary: 
      Dental plaque score calculation and swabs of Oropharynx and teeth were collected on
      admission. For group I, Miswak stick was used 4 hourly for oral care. For group II, 0.12%
      Chlorhexidine/ toothbrush were used 4 hourly
    

Detailed description: 
      The selected patients were randomized into 2 groups by the conventional method of
      randomization. For each patient the following parameters were collected: patient data; age,
      gender; history of smoking; chronic health problems; history of drugs as steroids,
      chemotherapy, current antimicrobial therapy; and the primary cause of hospital and ICU
      admission and mechanical ventilation.

      Clinical examination included assessment of disease severity on admission by Acute Physiology
      and Chronic Health Evaluation (APACHE II) scoring system, oral and dental examination, and
      dental plaque score calculation. Oropharyngeal and dental swabs were collected on admission.

      The preventative VAP bundle was applied to all patients in both groups. For group I, Miswak
      was used for oral care, patient's teeth were brushed every 4 hours using a Miswak stick after
      scraping of half an inch bark from the stick end then Miswak tip was washed and compressed to
      make it brush like. Both buccal and lingual surfaces of teeth were brushed using mechanical
      method for plaque removal (in direction away from gingival margin,). The patient's tongue was
      brushed when possible and lip moisturizer was applied as needed. The brush like end of sewak
      stick was cut and replaced daily.

      For group II, the patient's teeth were brushed every 4 hours using a soft toothbrush with
      0.12% Chlorhexidine solution. Both buccal and lingual surfaces of teeth were brushed using
      mechanical method for plaque removal (in direction away from gingival margin,). The patient's
      tongue was brushed when possible and lip moisturizer was applied as needed. The toothbrush
      was boiled for one minute every day.

      Patients in both groups were monitored for the efficacy of oral care in term of plaque score
      and halitosis. Colonization of trachea, OPH, and dental plaque by potential respiratory
      pathogens (PRPs) as Staphylococcus aureus, Pseudomonas, Klebsiella, Proteus, Acinetobacter
      and E. coli species was identified by culturing of OPH swab, dental swab and endotracheal
      tube (ETT) aspirate on inclusion into the study and every 4 days thereafter till ICU
      discharge, 3 weeks of ICU stay, or death. Secondary endpoints included time to VAP and its
      incidence, duration of MV, ICU discharge, and mortality rate.

      VAP was diagnosed when patient developed; new and/or progressive infiltrates in chest
      radiograph plus two or more of the following; leucocytosis ≥ 12000/mm3 or leucopenia ≤
      4000c/mm3, fever > 38oC or hypothermia < 36oC, or mucopurulent secretion as evident by gross
      inspection. The clinically diagnosed VAP was confirmed by quantitative endotracheal aspirate
      at a cut off value ≥105 colony forming unit (cfu) /ml.
    

Intervention name(s): Oral care in mechanically ventilated patients
Intervention type(s): Procedure
Intervention description(s): Oral care comparing Chlorhexidine and toothbrush versus Miswak ( the twig of Arak, Salvadora perscia, tree)
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Prevention
Keywords: VAP; Oral care; Chlorhexidine; Miswak (Sewak)