‘Supporting seriously ill patients’ mouthcare is an important part of overall patient care. If oral hygiene is neglected, the mouth rapidly becomes dry and sore. The aim of good mouthcare for patients in hospital is to maintain oral cleanliness, prevent additional infection and reduce the likelihood of developing bacterial pneumonia.’ [PHE, 2020].
World Oral Health Day takes place every year on 20th March. It was established by the World Dental Federation to raise awareness of the need for better oral health, at every stage of life. This is particularly significant for patients in hospital; as there is evidence that hospitalisation is associated with a deterioration in oral health, [Terezakis, 2011].
Some groups of patients are at increased risk of developing mouth related problems including those with dementia or stroke; frail older people; oncology patients undergoing head and neck radiation / chemotherapy; and patients on a ventilator. [Doshi, 2019]
Ventilated patients are at particular risk of developing ventilator-assisted pneumonia; and the oral micro-ecosystem is a recognised reservoir for respiratory pathogens. Various pathogens have been detected in dental plaques, periodontal pockets and saliva, including S. pneumoniae and K. pneumoniae, [Dong, 2022]. As pneumonia carries up to a 25% mortality risk, [Sattar, 2023] it is essential that these patients receive optimum mouth care measures to help reduce this risk.
Patients who have had a stroke are likely to have dysphagia, which reduces oral clearance, leading to a negative impact on their oral health. This may be compounded by xerostomia (dry mouth), which can lead to an increase in dental decay, gum disease and thrush, [NHS, 2019].
The mouth is the perfect environment for the growth of microorganisms. Periodontal disease originates from these resident microbial species, when the balance between the host and the microbes is disrupted, [Dhir, 2013]. Some health conditions including diabetes and cardiovascular disorders are additional risk factors for periodontal diseases, [Liccardo, 2019].
Deterioration in a patient’s oral health has a negative impact on their general health, with links to cardiovascular and respiratory disease [Kotronia, 2021] . In the hospital setting, poor oral health is a factor in the development of hospital acquired infections including ventilator acquired pneumonia (VAP) which is the most common nosocomial infection in Intensive Care Units, [Gupta, 2016]. It can also lead to poor nutritional intake, longer hospital stays and increased costs of care, [Terezakis, 2011].
The Royal College of Nursing (RCN) recommends that mouth care should be part of the daily routine, to ensure a patient’s mouth is as healthy as possible. ‘Preventative measures can be provided such as high fluoride toothpaste or mouth rinses… to help prevent further oral health problems,’ [RCN, 2021].
Dental plaque is a biofilm which adheres to the teeth and oral surfaces. If it is not effectively removed, it becomes a reservoir of microorganisms that may cause dental and periodontal infections, [Maddi, 2013]. Most plaque hardens within 48 hours of formation, and within days it becomes difficult to remove. Elimination of the pathogenic biofilm is critical for treating oral disease, otherwise bacteraemia may result in systemic infections, [Maddi, 2013].
In 2019, the NHS (Health Education England), published a guide for hospital healthcare professionals setting out the principles and practice of good oral care. This included ‘having the right tools for mouth care on wards’, with detailed advice about oral hygiene [Doshi, 2019]. NICE guidance on oral health for adults in care homes, stresses the importance of providing daily support to meet mouth care needs, including cleaning products and prescribed mouthwashes or rinses, [NICE, 2016].
There is evidence that mouth rinses may help reduce or prevent plaque formation and also reduce gingival inflammation, [Takenaka, 2022]. RCN guidance recommends that ‘mouth rinses and washes can be used to swish around the mouth providing freshness and moisture. However, mouthwashes with alcohol should be avoided as this can cause the mouth to feel drier.’ [RCN, 2021].
Chlorhexidine is the main active ingredient found in most mouth washes. However, rinsing with chlorhexidine mouth rinse for 4 weeks or longer causes extrinsic tooth staining. In addition, other adverse effects such as calculus build up, transient taste disturbance and effects on the oral mucosa have been reported, [James, 2017].
Another available molecule is octenidine dihyrdrochloride and there have been a number of clinical studies evaluating the efficacy and acceptability of a mouth wash containing octenidine.
In a multi-centre, randomised clinical trial octenidine was found to inhibit plaque formation and regrowth, whilst maintaining gingival health. This led the study authors to conclude that in clinical situations ‘when individual plaque control is compromised, rinsing with octenidine mouthwash is recommended to maintain healthy oral conditions,’ [Jockel-Schneider, 2021].
Another study investigated the antibacterial efficacy of octenidine and chlorhexidine mouth rinse solutions. octenidine was found to be the most effective in substantially reducing total bacterial counts. Octenidine also provided statistically significant reductions of 39% less plaque, 50% less gingivitis, and 60% fewer gingival bleeding sites, [Malhotra, 2016].
Significantly less tooth discolouration and staining has been recorded with octenidine containing mouth wash compared to a chlorhexidine based one, [Sarembe, 2024].
A placebo controlled, randomised clinical trial concluded that ‘due to its low toxicity and pronounced antibacterial properties, octenidine dihydrochloride is a promising candidate for the use in antiseptic mouth rinses,’ [Lorenz, 2018].
octenident® mouth wash
octenident is a hygienic mouth wash which inhibits pathogens and reduces odour producing bacteria in the oral cavity. Regular use ensures the mouth feels clean and fresh. It is chlorhexidine and alcohol free.
References
Dhir S. Biofilm and dental implant: The microbial link. J Indian Soc Periodontol. 2013;17(1):5-11.
Dong J, Li W, Wang Q, et al. Relationships Between Oral Microecosystem and Respiratory Diseases. Front Mol Biosci. 2022;8:718222. Published 2022 Jan 4
Doshi 2019 Mouth Care Matters A guide for hospital healthcare professionals Second Edition, NHS, Health Education England
Gupta A, Gupta A, Singh TK, Saxsena A. Role of oral care to prevent VAP in mechanically ventilated Intensive Care Unit patients. Saudi J Anaesth. 2016;10(1):95-97.
James P, Worthington HV, Parnell C, et al. Chlorhexidine mouthrinse as an adjunctive treatment for gingival health. Cochrane Database Syst Rev. 2017;3(3):CD008676. Published 2017 Mar 31.
Jockel-Schneider Y, Schlagenhauf U, Petsos H, et al. Impact of 0.1% octenidine mouthwash on plaque re-growth in healthy adults: a multi-center phase 3 randomized clinical trial. Clin Oral Investig. 2021;25(7):4681-4689.
Kotronia E, Brown H, Papacosta AO, et al. Oral health and all-cause, cardiovascular disease, and respiratory mortality in older people in the UK and USA. Sci Rep. 2021;11(1):16452. Published 2021 Aug 12.
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Lorenz K, Jockel-Schneider Y, Petersen N, et al. Impact of different concentrations of an octenidine dihydrochloride mouthwash on salivary bacterial counts: a randomized, placebo-controlled cross-over trial. Clin Oral Investig. 2018;22(8):2917-2925.
Maddi A, Scannapieco FA. Oral biofilms, oral and periodontal infections, and systemic disease. Am J Dent. 2013;26(5):249-254
Malhotra A, Bali A, Bareja R. 2016. Anti–bacterial efficacy of octenidine as a mouthwash. Int J Pharm Sci Res. 7(1):340–344.
NICE guideline, Oral health for adults in care homes Published: 5 July 2016, updated 2020 www.nice.org.uk/guidance/ng48 accessed 280224
Public Health England. (2014) Updated 2020, Delivering better oral health: an evidence-based toolkit for prevention. Third Edition https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention accessed 290224
Royal College of Nursing, Mouth Care Matters in End-of-Life Care, updated 2021
https://www.rcn.org.uk/Professional-Development/publications/mouth-care-matters-in-end-of-life-care-uk-pub-009-921 accessed 290224
Sarembe S, Michler N, Ufer C, Kiesow A. In Vitro Model to Evaluate the Development of Discolorations on Human Enamel Caused by Treatment with Mouth Rinses and Black Tea Considering Brushing. Eur J Dent. Published online January 23, 2024.
Sattar SBA, Sharma S. Bacterial Pneumonia. [Updated 2023 Aug 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513321/
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Terezakis E, Needleman I, Kumar N, Moles D, Agudo E. The impact of hospitalization on oral health: a systematic review. J Clin Periodontol. 2011;38(7):628-636.
