Improvement of oral care in emergency setup including acute skin failure

Improvement of oral care in emergency setup including acute skin failure


When the caregiver is preoccupied with other crucial activities including hourly patient movement, frequent feeding, cleaning, and properly timing medicine, oral care in patients with dermatological emergencies typically takes a second seat. It is debatably disregarded since it is viewed as being less significant. According to a research [1], emergency room nurses give oral care a score of 53.9 out of 100 for relevance.

This essay makes an effort to emphasise the value of maintaining dental health in the midst of daily activities since it contributes more than is often recognised to the quick recovery of dermatological emergency patients.

The value of oral hygiene

Diseases, oral health, and nutrition all work together in a positive way. The condition of your general health and nutrition depends on how well your mouth feels. [1] Even native bacteria can induce illness in the absence of excellent health and immunity, and an infection focus can swiftly expand to adjacent tissue planes. Patients with oral cancer, anyone in an intensive care unit, patients with extensive mucocutaneous lesions like those in pemphigus, Stevens Johnson syndrome, etc., and people with severe oral candidiasis secondary to immunosuppression, whether congenital or acquired, are among the dermatological conditions where oral health should be prioritised.

Dental Microbiome

According to studies, the oropharyngeal flora of critically sick patients changes from its usual predominance of Gram positive streptococci to one that is dominated by Gram negative organisms, including infections that may cause ventilator-associated pneumonia (VAP). Pathogens including Staphylococcus aureus and Streptococcus pneumoniae that cause VAP are primarily found in the oral cavity. [2]

dental tartar

Dental plaque is a biofilm that forms on tooth surfaces and acts as a reservoir for diseases in people with poor dental hygiene. It is a living space for bacteria.

oral defence

Immunities, both innate and adaptive, are crucial for limiting the development of bacteria in the oral cavity. Salivary flow and immunological salivary components like IgA and lactoferrin affect oral immunity.

The following factors can lead to poor oral health in bedridden patients: [3]

Primary medical condition or its management: Sjogren’s syndrome and other illnesses, as well as some drugs like antihistaminics, can all contribute to xerostomia.

ICU equipment: Many seriously ill patients have airways, endotracheal tubes, and feeding tubes in place that pass via the mouth cavity or nasopharynx. Placing such devices could force patients to keep their mouths open all the time, which could contribute to xerostomia, which increases dental plaque buildup and decreases immunological components in saliva.

Inability of patients to perform their own oral hygiene: Critically ill patients have limited oral self-care and water intake to combat xerostomia, whereas patients with dermatological disorders such toxic epidermal necrolysis (TEN), Stevens Johnson disease, and oral pemphigus have enhanced salivation that supports natural oral hygiene.

A combination of the following disorders, such as candidiasis, ulcers, stomatitis, glossitis, halitosis, gingivitis, periodontitis, and odontogenic infection, may present as common oral symptoms in a patient with a dermatological emergency (based on clinical experience). One of the most prevalent oral signs of acute skin failure, which may be brought on by impaired epithelial integrity or steroid therapy, is pseudomembranous candidiasis.

Warm saltwater rinses

This is one of the most straightforward and fundamental techniques for maintaining oral hygiene. The patient is instructed to gargle at least three times a day, preferably right after meals, with warmed normal saline or a home-made solution of warm salt water (in the proportion of 1 tsp salt to 2 glasses of water).


In terms of plaque removal and gingival stimulation, toothbrushes are the greatest mechanical oral care equipment and outperform foam swabs. The usage of electronic toothbrushes, which don’t require a lot of arm motion and effectively remove plaque, is an option for bedridden patients. The best toothbrushes for individuals with swallowing problems include those with severe Stevens Johnson syndrome, TEN, and oral pemphigus. A suction reservoir in this instance removes the accumulated toothpaste foam and saliva, lowering the risk of choking or aspiration pneumonia.


Foam swabs stimulate the mucosa and enhance saliva flow, which boosts local oral immunity even if they are ineffective at removing plaque. While sodium bicarbonate and hydrogen peroxide swabs are efficient at clearing debris, they can burn if improperly diluted. Lemon and glycerin swabs were once used to increase salivation but have since been discontinued due to negative side effects.


Due to its many beneficial qualities, chlorhexidine is regarded as the “gold standard mouthwash” [5],[6] [Table – 1]. However, when using chlorhexidine, the following safety measures must be performed. I Avoid using right before or right after applying tooth paste (interaction with anionic surfactants in the toothpaste will reduce the effective delivery of active form of chlorhexidine to the tooth surface). ii) Use toothpaste at least 30 minutes before applying chlorhexidine. iii) Rinse off excess toothpaste before using chlorhexidine. Sprays of chlorhexidine are additionally offered.

supporting treatment

This include maintaining appropriate hydration, general care, use of topical anaesthetics (such as lignocaine 2 percent) and analgesics (such as diclofenac and benzydamine hydrochloride 0.15 percent) for uncomfortable conditions.

Final treatment

This includes topical antibiotics like tetracycline mouthwash and antiseptic mouthwashes like triclosan 0.15 percent (empty cap 250 mg in 5-10 ml of water and rinse four times daily). When necessary, topical/systemic antifungal medications like fluconazole and clotrimazole as well as topical corticosteroids like the 0.1 percent triamcinolone acetonide in Orabase are utilised.


An individual’s oral health has a significant impact on their overall health. Supportive dental care is crucial for the maintenance of a patient’s health who is bedridden or ill, whether it be done mechanically or in conjunction with medication. Evidence-based oral care strategies for sick and bedridden people have not yet been developed. Studies are urgently needed to discover the optimal practises for dental care for a critically sick patient’s overall health.

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