Hospital-acquired pneumonia (HAP) is a significant cause of illness and death among patients requiring hospitalization. However, little is known about the effectiveness of potential prevention strategies. A new study in JAMA Internal Medicine investigated the clinical impact of daily toothbrushing on the incidence of HAP and its consequences.
Study: Daily Toothbrushing and Hospital-Acquired Pneumonia. Image source: TShaKopy / Shutterstock
Approximately one in a hundred hospitalized patients develops HAP, which not only jeopardizes their health and that of others but also increases the likelihood of delayed recovery and higher treatment costs. The risk is higher in patients with mechanical ventilation (MV) who have been intubated compared to others. However, non-ventilated patients make up a larger proportion of HAP cases (NV-HAP).
Both patient groups have similar HAP mortality rates. The lack of data on clinical outcomes after different prevention approaches has hindered the implementation of uniform strategies to mitigate this risk.
Careful oral hygiene has been highlighted as a potentially very effective measure to reduce the aspiration of oral organisms, whether micro or macroaspiration. This is supported by the finding that the same organisms are present in the mouth and lungs. This has led to the use of oral antiseptics such as chlorhexidine in ventilated patients.
However, this antiseptic may be associated with higher mortality rates, and it has not been shown to reduce infectious complications in such patients. An alternative approach is to carefully and regularly brush teeth, as recommended by the Society for Healthcare Epidemiology of America, excluding chlorhexidine. This is based on the results of lower ventilator-associated pneumonia and other favorable outcomes in patients who regularly brushed their teeth.
The small size of these studies and the lack of consensus on the relationship between toothbrushing and reduced HAP-associated mortality, duration of MV, and overall hospital stay, as well as the use of antibiotics, motivated the current meta-analysis, which included all relevant studies in this area.
The study included 15 randomized controlled trials (RCTs) involving over 2,800 patients, with approximately 80% being admitted to the intensive care unit (ICU) and the rest to other departments. Overall, nasal and oral intubation were included, with about one-fifth of the patients having a tracheostomy.
In most studies, chlorhexidine was used in the intervention and control groups in addition to or instead of toothbrushing. Some used toothpaste for plaque, povidone-iodine, saline solution, or purified water instead of chlorhexidine.
What Did the Study Find?
The results show that the incidence of HAP in those who brushed their teeth daily was significantly lower by more than one-third. This meant that for every 12 patients who regularly brushed their teeth, the incidence of pneumonia decreased by one case.
For ventilated patients, there was a 30% lower incidence of pneumonia, but this was not observed in patients under invasive mechanical ventilation (IMV). The risk of HAP in non-ventilated patients (NV-HAP) was reduced by 15% in patients admitted for medical problems, but not in surgical patients.
Two studies focusing on NV-HAP showed a 70% decrease in the risk of pneumonia in patients who regularly brushed their teeth.
Patients also spent an average of 1.2 days less time on ventilation and spent an average of 1.3-2 days less in the ICU. The mortality rate among ICU patients decreased by one-fifth.
It was found that twice-daily toothbrushing is as effective as more frequent toothbrushing. In most cases, toothbrushing was performed by nursing staff, seldom by dentists.
There were minimal effects on the length of hospital stay outside the ICU or the duration of antibiotic use.
What Are the Implications?
The study appears to support extensive efforts to promote regular toothbrushing at least twice daily for hospital patients. „Daily toothbrushing may be associated with significantly lower HAP rates, lower ICU mortality rates, a shorter duration of mechanical ventilation, and a shorter ICU stay.“
Compared to previous studies, this study is more comprehensive and therefore better able to identify actual changes in VAP outcomes after toothbrushing. The strength of evidence supporting the above conclusion suggests that hospital patients, especially those under IMV, should routinely perform toothbrushing as part of their standard care, given the documented reduction in pneumonia and mortality.
Further research is needed to answer questions about the importance of the type of toothpaste used, the need for tongue cleaning, as well as bowel cleansing or decontamination. Despite the study’s limitations, it serves as evidence for the need for „guidelines and programs to promote daily toothbrushing for hospitalized patients, especially those under mechanical ventilation.“