Assessment of oral changes in 2692 intensive care unit patients: a cross-sectional study

doi:10.21203/rs.3.rs-4369960/v1

Objectives

To identify oral changes in patients admitted to an intensive care unit (ICU).

Materials and Methods

Retrospective, cross-sectional, descriptive study. The following data were collected at a high-complexity referral center in northeastern Brazil between 2021 and 2024: sex, age, cause of hospitalization, ventilatory support, dental condition, and type of oral changes.

Results

A total of 2,692 patients admitted to the ICU were evaluated; 52.1% of the patients were male and the mean age was 69.98 years (± 19.53). Oral changes were detected in 56.98% of the patients and odontogenic infections were the most prevalent (41.49%). The presence of oral changes was significantly associated with male sex (p < 0.001), age between the 6th and 7th decade of life (p < 0.001), ventilatory support (p = 0.037), being partially dentate (p < 0.001), and the number of teeth (p < 0.001).

Conclusion

The prevalence of oral changes was high in the sample and male patients had a higher risk of developing these changes.

Clinical Relevance:

The results permit to characterize the incidence of oral changes in this patient profile, reinforcing the importance of the dentist as a member of multidisciplinary care teams.

Intensive care unit. Oral health. Oral Alteration. Diagnosis

The intensive care unit (ICU) is a specialized area for critically ill patients who require a higher level of healthcare [1, 2]. Patients admitted to the ICU require multidisciplinary and integrated care since aggravation of their health, changes in routine activities, and invasive and unpredictable procedures are factors that elevate their stress level and that make their management difficult, with consequent undervaluation of oral care [3–5].

Most ICU patients exhibit oral lesions and infectious foci before admission, including dental caries, residual roots, periodontal disease, and gingivitis [6]. Furthermore, these patients may develop oral changes resulting from medication use secondary to systemic changes and/or ventilatory support, which can involve different tissues such as the mucosa, bones, teeth, and salivary glands [2, 3, 7–10].

The demographic profile and the incidence of oral changes have been well established for different groups of patients, including the elderly, nursing home patients, and hospitalized patients [11–13]. However, knowledge about the incidence of oral changes in ICU patients is limited [2, 14]. Such studies are important since they provide reliable data on the main diagnoses that affect this population [6, 10], in addition to contributing to the development of prevention and treatment strategies [14]. Considering the paucity of these data, the objective of the present study was to evaluate the incidence of oral changes and the demographic profile of patients admitted to an ICU.

Study design and ethical issues

This cross-sectional study (2021–2024) was approved by the Ethics Committee of Real Hospital Português de Beneficência (No. 5.727.884) and was conducted in accordance with the ethical principles of the Declaration of Helsinki.

Sample

The sample consisted of patients admitted to the ICU who underwent routine clinical examination of the oral cavity. Patients older than 18 years who were evaluated by the hospital’s dentistry team with experience in oral medicine and who had stayed at least 24 hours in the ICU were included. Patients who could not be moved due to medical request and patients with systemic instability or any other condition that impaired examination were excluded.

Data collection

Demographic and clinical data were collected from the medical records (sex, age, cause of hospitalization, and type of ventilatory support). The type of ventilatory support was categorized as follows: spontaneous breathing, use of a nasal catheter, use of a mask, orotracheal intubation, or tracheostomy.

All patients underwent routine oral examinations using personal protective equipment, artificial light, tongue depressors, and sterile gauze. Thorough oral examination was performed and included the oral mucosa and teeth. The lips, oral vestibule, gingiva/alveolar ridge/alveolar mucosa, buccal mucosa, retromolar region, tongue (dorsum, border, apex, and belly), floor of the mouth, hard and soft palate, palatine tonsils, and oropharynx were inspected. In addition, teeth were counted and the patients were classified as edentulous or dentate (partially or fully). The use of a prosthesis was also considered.

Oral changes were identified and classified using an adaptation of the method proposed by Eduardo et al. [14] based on their etiology: 1) Odontogenic infections – any change of endodontic and/or periodontal origin, including fractured teeth, residual tooth roots, and dentoalveolar abscesses of endodontic origin [6, 10, 15]. Gingivitis was defined when the gingival margin and interdental papillae appeared swollen and red [6]. Periodontal disease was clinically defined based on the presence of suppuration at the gingival margin, tooth mobility and dental calculus. Periodontal/gingival abscesses and pericoronitis were also considered. 2) Clinical conditions suggestive of salivary changes. Lip dryness was characterized by an opaque, friable or scaly red border, which may contain ulcerations, fissures or crusts [16], while oral mucosa dryness was defined based on the absence of saliva in the sublingual region or adherence of the wooden tongue depressor to the oral cavity [16]. 3) Soft tissue lesions – changes in mucosal integrity of non-infectious origin such as traumatic ulcers, thermal burns, mucositis, and Graft-versus-host disease [17, 18]. 4) Non-odontogenic infections – clinical appearance of the lesions suggesting a fungal, viral, or bacterial origin. Oral changes compatible with candidiasis were classified as pseudomembranous candidiasis, chronic atrophic candidiasis (prosthetic stomatitis), linear gingival erythema, angular cheilitis, median rhomboid glossitis, and acute atrophic candidiasis [19]. Viral infections were classified as recurrent herpes simplex and herpes zoster, while bacterial infections were classified as bullous impetigo [20, 21]. 5) Vascular disorders – bleeding was defined as any source of bleeding that was not of periodontal/gingival origin and that could be due to a traumatic injury to the mucosa or dryness [6]. Petechiae/ecchymosis/hematoma and edema were also included [14]. The presence or absence of the oral changes and their number were identified for each patient.

Data analyses

Descriptive and quantitative data analyses were performed using the Statistical Package for the Social Sciences for Windows, v.20.0 (SPSS, Inc., Chicago, IL, USA). Pearson’s chi-square test was applied to evaluate the association between categorical variables and the strength of the association was obtained by the odds ratio (OR) and respective confidence intervals. The Mann-Whitney test was used to compare two categories of numerical variables. A p value ≤ 0.05 was adopted.

A total of 2,692 patients admitted to the general ICU were evaluated by the dentistry team of the hospital. There were 1,402 (52.1%) male patients and 1,290 (47.9%) female patients (male-to-female ratio of 1.08:1). The mean age of the patients was 69.98 years (± 19.53), with a majority of patients in the 8th and 9th decades of life. The main cause of hospitalization was lung disease (23.0%), followed by cerebrovascular diseases (13.6%). In addition, 36.8% of the patients required some type of ventilatory support. The most common dental condition was partially dentate (59.8%) and 41.4% of the patients used a prosthesis (Table 1).

Tabela 1 – Demographic and clinical characteristics of patients admitted to the ICU

Demographic profile and clinical characteristics	n (%)
Gender
Male	1402 (52,1)
Female	1290 (47,9)

Age frequency
< 39	256 (9,5)
40 a 49	194 (7,2)
50 a 59	273 (10,1)
60 a 69	411 (15,3)
70 a 79	560 (20,8)
80 a 89	590 (21,9)
>90	408 (15,2)

Reason for admission to ICU
Respiratory	620 (23,0)
Cerebrovascular diseases	365 (13,6)
Shock	336 (12,5)
Postoperative	334 (12,4)
Cardiovascular diseases	222 (8,2)
Gastrointestinal/Hepatic conditions	188 (7,0)
Change in level of consciousness	149 (5,5)
Kidney conditions	112 (4,2)
Trauma	76 (2,8)
Metabolic change	70 (2,6)
Self-extermination	65 (2,4)
Infection condition	39 (1,4)
Epilepsy	32 (1,2)
Malignant conditions	29 (1,1)
Haematological	23 (0,9)
Other	26 (0,7)

Ventilation
Environment ventilation	1700 (63,2)
Ventilation mask	373 (13,9)
Nasal catheter	261 (9,7)
Orotracheal intubation	258 (9,6)
Tracheostomy	100 (3,7)

Dental condition
Partially edentulous	1611 (59,8)
Toothed	570 (21,2)
Edentulous	428 (15,9)
Missing information	83 (3,1)

Use of prosthesis
Yes	1115 (41,4)
No	1577 (58,6)

Oral changes were observed in 1,117 patients (56.98%). The most prevalent changes were odontogenic infections (41.49%), followed by altered saliva production (13.11%) and soft tissue lesions (9.40%) (Table 2). Among odontogenic infections, 30.2% were of gingival/periodontal origin (Fig. 1A) and 22.47% were of endodontic origin (Fig. 1B). Altered saliva production was responsible for 13.11% of the oral changes (Fig. 1C). Among soft tissue lesions (9.40%), traumatic ulcers were the most common (8.73%) (Fig. 1D). Oral candidiasis accounted for the majority of non-odontogenic infections (8.69%) (Fig. 1E); however, there were also cases of herpes zoster (0.04%) with oral manifestation and bullous impetigo (0.04%). Vascular disorders (3.90%) were the least prevalent changes (Fig. 1F). At least one type of oral change was observed in 55.22% of the patients (Table 2).

Table 2

Frequency and type of oral changes in ICU patients
Type of oral alteration	n (%)
1. Odontogenic infection	1117 (41,49)
1.1. Infections of gingival/periodontal origin	813 (30,20)
1.1.1. Gingivitis	790 (29,35)
1.1.2. Tooth mobility	50 (1,86)
1.1.3. Periodontal abscess	3 (0,11)
1.1.4. Pericoronitis	1 (0,04)
1.2. Infections of endodontic origin	605 (22,47)
1.2.1 Tooth fracture	467 (17,35)
1.2.2. Residual root	279 (10,36)
1.2.3. Periapical abscess	7 (0,26)
2.0. Clinical conditions suggestive of salivary changes	353 (13,11)
2.1. Oral mucosa dryness	207 (7,69)
2.1. Dry lips	184 (6,84)
3.0. Soft tissue lesions	253 (9,40)
3.1. Traumatic ulcer	235 (8,73)
3.2. Mucosite	19 (0,71)
3.3. GVHD	1 (0,04)
3.4. Thermal burn	1 (0,04)
4.0 Non-odontogenic infections	242 (15,77)
4.1. Oral candidosis	234 (8,69)
4.1.2. Pseudomembranous candidosis	144 (5,35)
4.1.3. Denture stomatitis	26 (0,97)
4.1.4. Linear gingival erythema	23 (0,85)
4.1.5. Angular cheilitis	19 (0,71)
4.1.6. Median rhomboid glossitis	18 (0,67)
4.1.7. Acute atrophic candidosis	10 (0,37)
4.2. Viral infection	7 (0,26)
4.2.1. Recurrent herpes simplex	6 (0,22)
4.2.3. oral herpes zoster	1 (0,04)
4.3. Bacterial infection	1 (0,04)
4.3.1. Bullous impetigo	1 (0,04)
5.0. Vascular disorders	105 (3,90)
5.1 Bleeding	52 (1,93)
5.2. Petechiae	47 (1,75)
5.3. Edema	6 (0,22)
Total	1534 (56,98)
Frequency of oral changes
Only one alteration	847 (55,22)
Two alterations	424 (27,64)
≥ Three alterations	263 (17,14)
GVHD = Graft-versus-host disease

A statistically significant association was found between the presence of oral changes and male sex (p < 0.001), age between 50 to 59 and 60 to 69 years (p < 0.001), ventilatory support (p = 0.037), and being partially dentate (p < 0.001) (Table 3). There was also a statistically significant association between the number of teeth and the presence of oral changes (p < 0.001) (Table 4).

Table 3

– Association of the presence of oral changes with sex, age group, use of prosthesis, ventilatory support and dental condition
	oral change
Clinical and demographic characteristics	Yes	No	Total	OR (IC 95%)	p value
	n (%)	n (%)	n (%)
Gender					p ⁽¹⁾ < 0,001*
Male	862 (61,5)	540 (38,5)	1402 (100,0)	1,5 (1,3 a 1,7)
Female	672 (52,1)	618 (47,9)	1290 (100,0)	1,0
Age groups					p ⁽¹⁾ < 0,001*
≤ 39	126 (49,2)	130 (50,8)	256 (100,0)	1,0
40 a 49	102 (52,6)	92 (47,4)	194 (100,0)	1,1 (0,8 a 1,7)
50 a 59	171 (62,6)	102 (37,4)	273 (100,0)	1,7 (1,2 a 2,5)
60 a 69	256 (62,3)	155 (37,7)	411 (100,0)	1,7 (1,2 a 2,3)
70 a 79	324 (57,9)	236 (42,1)	560 (100,0)	1,4 (1,1 a 1,9)
80 a 89	353 (59,8)	237 (40,2)	590 (100,0)	1,5 (1,1 a 2,1)
≥ 90	202 (49,5)	206 (50,5)	408 (100,0)	1,0 (0,7 a 1,4)
Prosthesis					p ⁽¹⁾ = 0,126
Yes	616 (55,2)	499 (44,8)	1115 (100,0)	1,0
No	918 (58,2)	659 (41,8)	1577 (100,0)	1,7 (1,5 a 2,1)
Total	1534 (57,0)	1158 (43,0)	2692 (100,0)
Ventilation					p ⁽¹⁾ = 0,037*
Ventilation mask	208 (55,8)	165 (44,2)	373 (100,0)	1,0
Nasal catheter	147 (56,3)	114 (43,7)	261 (100,0)	1,0 (0,7 a 1,4)
Orotracheal intubation	156 (60,5)	102 (39,5)	258 (100,0)	1,2 (0,9 a 1,7)
Tracheostomy	71 (71,0)	29 (29,0)	100 (100,0)	1,9 (1,2 a 3,1)
Total	592 (58,7)	410 (41,3)	992 (100,0)
Dental condition					p ⁽¹⁾ < 0,001*
Partially toothed	1092 (67,8)	519 (32,2)	1611 (100,0)	6,5 (5,1 a 8,3)
Fully toothed	282 (49,5)	288 (50,5)	570 (100,0)	3,0 (2,3 a 4,0)
Edentulous	105 (24,5)	323 (75,5)	428 (100,0)	1,0
Grupo total	1479 (56,7)	1130 (43,3)	2609 (100,0)
(*) Result is statistically significant, (1) Pearson's chi-squared test

Table 4

– Association of the presence of oral changes with age, number of teeth and residual roots
	Oral alteration
	Yes	No	Total group
	Mean ± SD	Mean ± Sd	Mean ± SD	p value
	Median(P25; P75)	Median (P25; P75)	Median (P25; P75)
Age	70,21 ± 18,57	69,67 ± 20,73	69,98 ± 19,53	p ⁽¹⁾ = 0,735
	73,50 (59,00; 85,00)	74,00 (57,00; 86,00)	74,00 (58,00; 85,00)
Number of teeth	17,28 ± 9,73	14,91 ± 12,23	16,25 ± 10,94
	19,00 (9,00; 26,00)	16,00 (0,00; 28,00)	18,00 (6,00; 27,00)	p ⁽¹⁾ < 0,001*
Number of residual roots	2,83 ± 2,90		2,83 ± 2,90
	2,00 (1,00; 3,00)		2,00 (1,00; 3,00)
SD = Standard deviation, (*) Result is statistically significant, (1) Mann-Whitney's test

Patients admitted to the ICU may be affected by oral changes with different degrees of complexity, which require a personalized diagnosis and treatment. Therefore, studies characterizing these findings are needed [9, 14]. Knowledge about the incidence of oral changes in this patient profile is important since it contributes to the diagnosis and prevention of oral lesions. This article reports the largest series of patients admitted to an ICU in whom oral changes were evaluated. The prevalence of oral changes among ICU patients was 56.98% in the present study. This percentage agrees with Eduardo et al. [14] and Martins et al. [2] who reported a prevalence of approximately 51%. On the other hand, Steinle et al. [6] observed oral changes in 100% of the patients examined. This difference might be explained by the heterogeneity of the samples. Another factor to be considered are different levels of exposure to risk factors for the development of these changes such as ventilatory support, underlying disease, medication use, and advanced age [2, 9, 13, 14]. It is important to consider that the majority of patients admitted to the ICU already have oral changes before admission [6].

Regarding sex, our results indicate a male-to-female ratio of 1.08:1. However, we observed a statistically significant association between the presence of oral changes and male sex (p < 0.001). Martins et al. [2] reported a higher prevalence of female patients in the ICU but oral changes mainly affected male patients. It is believed that male patients seek health services less frequently. Thus, the low frequency of these changes in females may be related to a history of healthcare attendance and better oral hygiene practices [9].

Patients admitted to the ICU are generally older than 50 years [22]. In the present study, the mean age of the patients was 69.98 years (± 19.53). Aging can be a risk factor for oral changes since older patients often require multidrug therapies that can reduce saliva production. The repair process also suffers changes with advancing age, which may reduce the intensity and effectiveness of the immune response [13]. We found a statistically significant association between oral changes and the age ranges of 50 to 59 years and 60 to 69 years (p < 0.001).

Odontogenic infections accounted for 41.49% of oral changes detected in the present study. It is known that these infections are mainly caused by microbial biofilms [7, 23]. Despite the importance of the dentist as a member of the multidisciplinary care team in the ICU for diagnosing and treating oral changes, the nursing staff is usually responsible for maintaining the oral hygiene of ICU patients, which is fundamental for the prevention of infections [2, 3, 8]. Despite a decline in mutilating dental treatments, the rate of tooth extraction continues to be high in Brazil [24]. This tooth loss can be observed in our sample in which only 570 (21.2%) patients had complete dentition, while 1,611 (59.8%) patients had lost at least one tooth before being admitted to the ICU. Our results revealed a statistically significant association of oral changes with the presence of teeth (p < 0.001) and the mean number of teeth (p < 0.001). When fractured, the tooth structure can cause trauma to the mucosa. In addition, teeth and their supporting structures retain biofilms, favoring infectious processes. Oral hygiene protocols must therefore be developed for these patients [23].

Other factors have been reported as risk factors for the occurrence of soft tissue changes in the mouth, such as invasive or noninvasive ventilatory support. Prolonged use of ventilatory support causes mucosal dryness, promotes the growth of microorganisms, and increases the risk of soft tissue lesions [5]. In the present study, 36.8% of the patients required some type of ventilatory support, which was significantly associated with the presence of oral changes (p = 0.037).

The orotracheal tube is one of the main medical devices associated with pressure injuries [9, 22]. It is known that the intubation process is one of the major causes of trauma in the ICU and the occurrence of these injuries [5, 14]. In our sample, traumatic ulcers were the most common soft tissue lesion (8.73%). Other tissue lesions such as mucositis (0.71%) were also observed. Cancer patients are at greater risk of developing mucositis as a result of antineoplastic treatment; however, the treatment is discontinued when these patients are admitted to the ICU. Silva et al. [8] observed a higher incidence of these lesions (20%) among these patients. These divergent findings might be related to the fact that cancer was one of the least common causes of ICU admission in our study.

Ventilatory support opens a window for the growth of microorganisms, increasing the risk of infections such as nosocomial pneumonia and mechanical ventilation-associated pneumonia, which occur when pathogenic microorganisms migrate to the respiratory tract [25, 26]. Some conditions can favor the development of this type of pneumonia, including dry mouth, aspiration of secretions, changes in the microbiota (bacterial and/or fungal: oral candidiasis), and oropharyngeal. In the present study, the prevalence of oral candidiasis was 8.69%. Different factors can trigger the transition of Candida from the commensal to the pathogenic form, such as immunosuppression, malnutrition, advanced age, endocrine disorders, and the use of corticosteroids and broad-spectrum antibiotics [19]. In ICU patients, fungal infections may be responsible for aggravation of the clinical condition, starting in the oral cavity, and may lead to death. Oral hygiene is a tool to prevent this type of infection [25].

Mucosal dryness is a common finding in patients admitted to the ICU [10] and may be a consequence of reduced salivary flow and/or sialochemical changes secondary to medication use, stress, and dehydration [10, 16, 27]. In our sample, dry mouth accounted for 7.69% of oral changes. Furthermore, lip dryness is usually caused by conditions inherent to the physical structure of the ICU such as low temperatures (air conditioning) and can be prevented and treated [28]. We observed dryness of the lip vermilion in 6.84% of the patients. In addition to causing pain, dry lips can represent a gateway for secondary infections when the skin barrier is damaged [5, 10].

The present population was heterogeneous in terms of age, cause of ICU admission, ventilatory support, and dental condition, which may be a limitation of this study. Another limitation is the difficulty in evaluating the oral cavity of some patients due to the limited visual field, especially in the case of intubated patients or patients with involuntary muscle contractions. Thus, some changes may have been underreported because of diagnostic difficulties, such as caries and periodontal disease. Longitudinal studies including the analysis of confounding factors are suggested.

In conclusion, the prevalence of oral changes was high among ICU patients and male patients had a higher risk of developing these changes, with odontogenic infections being the most common. Physical examination of the oral cavity of ICU patients should be included in the care protocols of any patient admitted to this unit regardless of the cause of admission. This examination should be performed frequently and systematically by a trained professional in order to enable the diagnosis and treatment of these changes, reinforcing the importance of dentists as an integral part of multidisciplinary care teams in the ICU.

Conflict of interest

The authors have no conflicts of interest to disclose.

Ethical approval
The study was approved by the Ethics Committee of Real Hospital Português de Beneficência (No. 5.727.884)

Consent to participate
The informed consent was obtained from all individual participants or responsibilities included in the study.

Funding

Not applicable

Author Contribution

All authors contributed to the study conception and design. W.R.S.; H. A. G. O.; and A. X. L. C. T. B.: Conceptualization, project admin¬istration, methodology, formal analysis, writing – original draft. A. P. V. S.; A. C. M. M. A.; L. F. G.; L. F. S. C.; and U. D. N. T. C.: con¬ceptualization, writing - review and editing. K. R.: Research design, analysis, data interpretation, writing and critical analysis. All authors certify that they have participated sufficiently in the work to take public responsibility for the content, including participation in the concept, design, analysis, writing, or revision of the manuscript. All authors read and approved the final manuscript.

Acknowledgement

This work was supported by the Postgraduate Program in Dentistry of the University of Pernambuco, the Coordination for the Improvement of Higher Education Personnel (CAPES), and the Carlos Chagas Filho Foundation for Research Support in the State of Rio de Janeiro (FAPERJ).

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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No competing interests reported.

Assessment of oral changes in 2692 intensive care unit patients: a cross-sectional study

Status:

Version 1

Abstract

Objectives

Materials and Methods

Results

Conclusion

Clinical Relevance:

Figures

Introduction

Methods

Study design and ethical issues

Sample

Data collection

Data analyses

Results

Discussion

Declarations

Conflict of interest

Ethical approval
The study was approved by the Ethics Committee of Real Hospital Português de Beneficência (No. 5.727.884)

Consent to participate
The informed consent was obtained from all individual participants or responsibilities included in the study.

Funding

Author Contribution

Acknowledgement

Data availability

References

Additional Declarations

Status:

Version 1

Assessment of oral changes in 2692 intensive care unit patients: a cross-sectional study

Status:

Version 1

Abstract

Objectives

Materials and Methods

Results

Conclusion

Clinical Relevance:

Figures

Introduction

Methods

Study design and ethical issues

Sample

Data collection

Data analyses

Results

Discussion

Declarations

Conflict of interest

Ethical approval The study was approved by the Ethics Committee of Real Hospital Português de Beneficência (No. 5.727.884)

Consent to participate The informed consent was obtained from all individual participants or responsibilities included in the study.

Funding

Author Contribution

Acknowledgement

Data availability

References

Additional Declarations

Status:

Version 1

Ethical approval
The study was approved by the Ethics Committee of Real Hospital Português de Beneficência (No. 5.727.884)

Consent to participate
The informed consent was obtained from all individual participants or responsibilities included in the study.