Hospital-acquired pneumonia (HAP) is a major cause of illness and death among hospitalized patients. However, little is known about the effectiveness of potential prevention strategies. A new study in JAMA Internal Medicine investigated the clinical impact of daily tooth brushing on HAP incidence and outcomes.
Study: Association between daily tooth brushing and hospital-acquired pneumonia. Image credit: TShaKopy / Shutterstock
About one in a hundred hospital patients develop HAP. This not only endangers their health and that of others, but increases the chances of delayed recovery and the cost of treatment. The risk is increased among mechanically ventilated (MV) patients who have been intubated relative to others. However, in terms of volume, non-ventilated patients make up a larger proportion of HAP (NV-HAP) cases.
Both groups of patients have similar mortality rates from HAP. The lack of data on clinical outcomes after various preventive approaches has prevented the adoption of uniform strategies to prevent this risk.
Careful oral hygiene has been highlighted as a potentially very effective intervention to reduce the absorption of oral organisms, either micro- or macro-aspiration. This is supported by the finding that the same organisms are found in the mouth and lungs. This has led to the use of oral antiseptics such as chlorhexidine in patients with MV.
However, this antiseptic may be associated with higher mortality rates and has not been shown to reduce infectious complications in such patients. An alternative approach is careful and regular tooth brushing, as recommended by the American Society for Public Health Epidemiology, excluding chlorhexidine. This is because of the findings of pneumonia associated with lower ventilation and other favorable outcomes among patients who brushed their teeth regularly.
However, the small size of these studies and the lack of consensus regarding the association of tooth brushing with lower HAP-related mortality, duration of MV, and total hospitalization and antibiotic use motivated the current meta-analysis, including of all relevant studies in this field.
The study included 15 randomized controlled trials (RCTs) involving, in fact, more than 2,800 patients, about 80% of whom were admitted to the intensive care unit (ICU) and the rest to other departments. Overall, nasal and oral intubation was included, with approximately one-fifth of patients having tracheostomies.
In most studies, chlorhexidine was used in addition to or instead of brushing in the intervention and control groups. Some used anti-plaque toothpaste, povidone-iodine, saline, or plain water instead of chlorhexidine.
What did the study show?
The results show that the incidence of HAP was significantly lower by over a third among those who brushed their teeth daily. This meant that for every 12 patients who brushed their teeth regularly, the incidence of pneumonia was reduced by 1 case.
MV patients had a 30% reduced incidence of pneumonia, but this was not seen among those on IMV. The risk of HAP in non-ventilated patients (NV-HAP) was reduced by 15% in those admitted for medical problems, but not in surgical patients.
Two studies looking at NV-HAP revealed a 70% reduction in the risk of pneumonia among patients with regular tooth brushing.
Similarly, patients had to spend less time in the MV, an average of 1.2 days, and spent an average of 1.3-2 days less in the ICU. The mortality rate among ICU patients also fell by a fifth.
Brushing your teeth twice a day has been found to be just as effective as more frequent brushing. In most cases, brushing was done by nursing staff and only occasionally by dental professionals.
There was little effect on length of hospital stay outside the ICU or duration of antibiotic use.
What are the consequences;
The study appears to support widespread efforts to promote regular tooth brushing at least twice a day among hospitalized patients. “Daily tooth brushing may be associated with significantly lower HAP rates, lower ICU mortality rates, shorter duration of mechanical ventilation, and shorter ICU length of stay.”
Compared with previous research, this study is more comprehensive and thus can better detect real changes in VAP outcomes after tooth brushing. The strength of the evidence supporting the above conclusion suggests that hospital patients, especially in IMV, should have regular tooth brushing as part of their standard care in view of the documented reduction in pneumonia and mortality.
Further research will be required to answer questions about the importance of the type of toothpaste used, the need for tongue cleaning, and bowel cleaning or disinfection. Despite the study’s limitations, it serves as evidence to suggest the need for “policies and programs to encourage daily tooth brushing in hospitalized patients, particularly those receiving mechanical ventilation.”
