Less daily oral hygiene is more in the ICU: yes
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LESS IS MORE IN INTENSIVE CARE
Less daily oral hygiene is more in the ICU: yes Brian H. Cuthbertson1,2,3,4* and Craig M. Dale5,6 © 2020 Springer-Verlag GmbH Germany, part of Springer Nature
Ventilator associated pneumonia (VAP) and halitosis can be considered to be the two scourges of the decade in the 2000s, one medical and one social of course. While these two problems may seem unrelated, both are conditions in which pressure to adopt oral therapies may result in more harm than good. VAP was certainly seen as the scourge of Critical Care Medicine and was identified as having ≥ 10% attributable mortality in early studies [1]. VAP prevention rapidly became the focus of Critical Care Quality Improvement Programs around the world [2] with healthcare organizations whose missions is “improving health and health care worldwide” jumping on the bandwagon and pushing the agenda forward with zeal [3]. They were supported in this odyssey by governmental and non-governmental organizations internationally, which described VAP as a treatable disease [4]. Oral care and ventilator care bundles came into vogue and all such guidelines contained the recommendation to prevent VAP using oral chlorhexidine solution. In sequence, chlorhexidine oral rinse became an accepted means to attenuate VAP and a social indicator of quality care [5]. The “social scourge” of halitosis was in fact a disease invented by pharmaceutical manufacturers to scare people into using their products—and it worked! Originally considered a surgical antiseptic, floor cleaner, and treatment for gonorrhea, listerine alcohol-based solution became the first over-the-counter mouthwash to “cure” bad breath [6]. The marketing transformation of a personal imperfection into an embarrassing medical condition changed personal oral hygiene practices worldwide. In organizing a desire to purchase the mouthwash, the manufacturer advertised bad breath as a widespread,
*Correspondence: [email protected] 1 Department of Critical Care Medicine, Sunnybrook Health Sciences Center, 2075 Bayview Avenue, Toronto, Canada Full author information is available at the end of the article
serious, and treatable disease. In reality, alcohol-containing mouthwashes may contribute to dry mouth and make halitosis worse by reducing or eliminating saliva. Our mouths need saliva to control bacteria, minimize inflammation, and to stay fresh, meaning that the lack of saliva can cause bad breath and dental disease [7]. Nevertheless, the pursuit of the perfect smile and freshest breath is now a compulsion to millions around the world, so why should it not be so for the critically ill in critical care, right? In these enlightened days, at the beginning of the 2020s, we know better of course (or we would do if we weren’t trying to deal with a global pandemic). It turns out that the attributable mortality for VAP is probably closer to 1% and our previous studies were grossly confounded [8]. Further, and concerningly, it turns out that oral chlorhexidine may actually be causing more harm tha
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