Growth Changes of Mouth Germs after Implementation of Oral

Hygiene Actions

Hamzah, Arie Utariani, Kohar Hari Santoso, Christrijogo Sumartono, Soni Sunarso, Sulistiawan,

Alsep Dolfi Luntungan

Department of Anesthesiology and Reanimation, Faculty of Medicine, Universitas Airlangga, Indonesia

Keywords: Severe Head Injury, Germs of the Oral Cavity, Oral Hygiene.

Abstract: Implementation of the oral hygiene according to procedures can reduce the growth of oral germs. The aim of

this study was to determine the growth changes of oral germ after the implementation of oral hygiene. The

subjects were all severe head injury patients who performed oral hygiene action in Intensive Observation

Room of Dr. Soetomo General Hospital Surabaya from June 1st to July 31st 2014. Samples were taken before

and after the action of oral hygiene and then the culture of bacteria were examined against 13 patients during

the period. Furthermore, a statistical analysis was performed with paired t-test to determine the amount of

germs and McNemar test was used to determine the germs, before and after the oral hygiene action. In 13

patients, the amount of germs were decreased and no amount of germs after the implementation of oral

hygiene action. The result of data analysis with paired sample t-test showed a significant result (p = 0.001).

The conclusion of this study was decreased of the germ’s number and no amount of germs after the

implementation of oral hygiene action.

1 INTRODUCTION

Oral hygiene is defined as those measures that are

necessary to attain and maintain oral health including

practices required to cleanse teeth, the periodontal

tissues and the mouth in general, and contribute to a

state of cleanliness in the oral cavity (Stallard et al,

1982). Poor maintenance of oral and dental hygiene

were associated with some dissease including caries

and respiratory dissease (Azarpazhooh et al, 2006;

Marsh, 2009). There are various microorganisms in

the oral cavity although it is commensal, it can be

pathogenic when the host response is disrupted

(Casadevall et al, 2000). Controlling homeostasis of

microbe that formed in dental plaque is very

important to prevent infection. Preservation of dental

plaque pH to normal level can be achieved by the

suppression of sugar catabolism and acid production

by the use of metabolic inhibitors in oral care

products, the consumption of non-fermentable

sweeteners in snacks, the stimulation of saliva flow,

therefore maintaining microbial homeostasis (Marsh,

2009). Use of chlorhexidine as oral rinse solution was

recommended among other solution, because it has

potent antimicrobial activity including gram-negative

bacteria (Berry et al, 2007).

Traumatic brain injury (TBI) is a major cause of

death and disability in the United States, which

contribute to about 30% of all injury deaths. TBI is

caused by a bump, blow, or jolt to the head that

disrupts the normal function of the brain, with

severity range from mild to severe (Taylor et al,

2017). Based on medical record in Dr. Soetomo

General Hospital Surabaya, there were 1,588 to 2,005

people with head injury every year, 195 to 467

patients among themwere severe brain injury

(Glasgow Coma Scale <8). The mortality rate for all

severity of brain injury varies from 6.17% to 11.22%.

It was found that the percentage of head injury

patients ranged from 10-20% in the resuscitation

room. This means almost have one patient with head

injury every 5 patients in the resuscitation room, as

well as in intensive observation room (IOR)

(Wahyuhadi et al, 2007). Patients with head injury

may experience various nursing problems including

impaired consciousness, impaired physical mobility,

and swallowing disorders. Patients with severe head

injury will experience a decrease in consciousness

which the patient will cause food swallowing

disorders through the mouth, and this could cause the

inflammation of the mucous membranes (Maas et al,

2008; AANS, 2016).

316

Hamzah, ., Utariani, A., Santoso, K., Sumartono, C., Sumarso, S., Sulistiawan, . and Luntungan, A.

Growth Changes of Mouth Germs after Implementation of Oral Hygiene Actions.

DOI: 10.5220/0008156503160319

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 316-319

ISBN: 978-989-758-494-7

Based on the facts and data mentioned above, the

researchers aimed to conduct a research on the growth

changes of oral germ after the implementation of oral

hygiene action in patients with severe head injury in

IOR unit of Dr. Soetomo General Hospital Surabaya.

2 METHODS

The study was a prospective observational

longitudinal study to analyze changes in oral

germgrowth before and after oral hygiene action in 13

patients with severe head injury. Sampling was

conducted at IOR of Dr. Soetomo General Hospital

Surabaya during June 1st to July 31st, 2014. The

inclusion criteria were patients with severe head

injury (GCS <8) treated for 1-2 days, aged 14-70

years, and patients were examined before and after

oral hygiene action. Data collecting process were

done after consent given to family of the patient.

Samples of germs collected, using swab, for culture

from the mouth of patients with a severe head injury

before and after oral hygiene action with intervals of

12 hours. Specimen then diluted, followed by

inoculation into isolation medium then incubation of

aerobic & anaerobic (37 ° C, for 18-24 hours) was

conducted. After the growth of germ found, then we

counted the colony and continued with the

identification of the germ.Furthermore, a statistical

analysis was performed using paired t-test to

determine the number of germs and Mc Nemar test to

determine the types of germs, before and after the oral

hygiene action.

3 RESULTS

Table 1: Characteristic of sample.

Characteristics

Result (n=13)

Sex

male

female

9 (69.2%)

4 (30.8%)

Age

range

mean (SD)

max= 62y.o; min= 14y.o

35.00 (+ 17.176)

Glasgow Coma

Scale

1X1

1X3

1X4

2X3

2X4

3 (23.1%)

2 (15.4%)

1 (7.7%)

4 (30.8%)

3 (23.1%)

(reference: internal data research)

Most of the sample in this study were male (69.2%),

with age varies from 14 to 62 y.o. Degree of

consciousness of the sample, based on Glasgow

Coma Scale, were mostly 2X3 (n=4). Verbal aspect

of consciousness could not be evaluate because all of

sample were using endotracheal intubation.

Table 2 showed the result of data analyze with

paired sample t test which obtained a significant

result (p = 0.001). Thus, there were significant

differences in the number of germs before and after

the implementation of oral hygiene action. After

those germ identified, Klebsiella pneumonia were

found in 6 patients (46.2%). This ammount then

reduced to 1 patient, after intervention of oral hygiene

were done. Other species that found before oral

hygiene were Proteus mirabilis, Pseudomonas

aeruginosa, Staphylococcus aureus, Streptococcus

viridans. After taking oral hygiene procedure, no

germ were found in 11 patients. Germ still found on

2 patients after oral hygiene, which identified as

Proteus mirabilis and Klebsiella pneumoniae.

Table 2: The number and types of germ before and after

Oral Hygiene.

Mean

Pre Oral

Hygiene

11.6154

9.41221

0.001

Post Oral

Hygiene

2308

59914

*significant (p<0.05)

Types of germs

Before OH

After OH

Frequency

(%)

Frequency

(%)

Klebsiella

pneumoniae (Rod

gram -)

6 (46.2 %)

1 (7.7%)

Proteus mirabilis

(Rod gram -)

1 (7.7%)

Pseudomonas

aeruginosa (Rod

gram -)

2 (15.4%)

Staphylococcus

aureus (Coccus gram

2 (15.4%)

Streptococcus

viridans (Coccus

gram +)

1 (7.7%)

Nothing

1 (7.7%)

(84.6%)

Total

13 (100%)

(reference: internal data research)

Growth Changes of Mouth Germs after Implementation of Oral Hygiene Actions

317

4 DISCUSSION

Dental plaque is an example of a biofilm which

naturally presents and supports the host in its defense

against invading microbes. The microbial

composition of dental plaque is diverse and remains

relatively stable over time (microbial homeostasis).

But under some circumstance, this microbial

homeostasis is disrupted, which leads to development

of unfavorable microorganism (Marsh, 2009). Severe

head injury cause decreased consciousness thus also

decrease swallowing reflex. It may leads to excessive

saliva and increases plaque formation of germs in the

oral cavity, which can be source of infection if it left

untreated (Wahyuhadi et al, 2017; Maas et al, 2008;

AANS, 2016). Thus oral hygiene is needed to control

microbialcolonization.

As shown in Table 2, there was a significant

change in oral germ growth (p = 0.001), prior to the

oral hygiene action and after the oral hygiene.

Implementation of oral hygiene action used

chlorhexidine 0.2%, which was a bisbiguanide-class

antiseptic. Chlorhexidine has bactericidal and

bacteriostatic effect on gram(+)bacteria and gram(-)

bacteria. It induce death of bacteria by causing cell

leakage and coagulation of intracellular compound. It

also can eliminate protozoa and virus in the oral

cavity. Positive charge or cation of Chlorhexidine

permeates to the tooth tissue, the acidic protein

covering the teeth, the oral mucosa, and the salivary

protein. The antiseptic absorbed by the tooth surface

has an anti-bacterial effect. Chlorhexidine can

significantly reduce the amount of plaque that formed

on tooth surfaces and reduced the number of bacteria

present in saliva (Sekino et al, 2004).

Other studies showed that patients with

susceptible age from 35 to 67 years who

usedchlorhexidine on the implementation of oral

hygiene action could decrease the amount of

colonization of oral bacteria and decreased the

incidence of nosocomial infection (Fourrier et al,

2010). The provision of chlorhexidine 0.2% as an

antiseptic on the implementation of oral hygiene

action every 12 hours can prevent the formation of

biofilms from bacteria thus it decreases the incidence

of infection (Panchabhai et al, 2009). The use of

chlorhexidine 0.2% also found to significantly

reduces ventilator-associated pneumonia incidence

(Tantipong et al, 2008).

5 CONCLUSION

There was a change in the number of germs before

and after the oral hygiene action. Statistical test

results (paired sample t-test) showed significant

differences (p = 0.001) between the number of germs

before and after the implementation of oral hygiene

action. In addition to decrease of number of germs

growth, most patients show no identifiable germs on

culture media, after taking oral hygiene procedure

ACKNOWLEDGEMENT

I would like to thanks to my friends whose willing to

finish this research with me. I would also like to give

my deepest thank to Dr. Soetomo General Hospital

Surabaya for give me oportunity to learn and do this

research. Last but not the least, I would like to thank

my family for always supporting me.

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