Daily Tooth Brushing and its Association with Pneumonia Risk

Importance 

Hospital-acquired pneumonia ( HAP) is the most common and morbid healthcare-associated infection, but limited data are available on effective prevention strategies.

Aim 

To determine whether daily tooth brushing is associated with lower rates of hospital-acquired pneumonia (HAP) and other patient-relevant outcomes.

Data sources 

We searched PubMed, Embase, Cumulative Index to Nursing and Allied Health, Cochrane Central Register of Controlled Trials, Web of Science, Scopus, and 3 trial registries from inception to March 9, 2023.

Study selection 

Randomized clinical trials of hospitalized adults comparing daily oral care with toothbrushing versus regimens without toothbrushing.

Data extraction and synthesis 

Data extraction and risk of bias assessments were performed in duplicate. The meta-analysis was performed using random effects models.

Main results and measures 

The primary outcome of this systematic review and meta-analysis was hospital-acquired pneumonia (HAP). Secondary outcomes included in-hospital and intensive care unit (ICU) mortality, duration of mechanical ventilation, length of hospital and ICU stay, and antibiotic use.

Subgroups included patients who received invasive mechanical ventilation versus those who did not, twice-daily versus more frequent toothbrushing, toothbrushing provided by dental professionals versus general nursing staff, electric versus manual toothbrushing, and studies with low versus high risk of bias.

Results 

A total of 15 trials met the inclusion criteria, including 10,742 patients (2,033 in ICU and 8,709 in non-ICU departments; effective population size was 2,786 after population reduction) to represent 1 cluster randomized trial in patients who are not in the ICU).

Tooth brushing was associated with a significantly lower risk of hospital-acquired pneumonia (HAP) (risk ratio [RR], 0.67 [95% CI, 0.56-0.81]) and mortality in the ICU (RR, 0.81 [95% CI, 0.69-0.95]). The reduction in pneumonia incidence was significant for patients who received invasive mechanical ventilation (RR, 0.68 [95% CI, 0.57-0.82) but not for patients who did not receive invasive mechanical ventilation (RR , 0.32 [95% CI: 0.05-2.02]).

Tooth brushing in ICU patients was associated with fewer days of mechanical ventilation (mean difference, −1.24 [95% CI, −2.42 to −0.06] days) and shorter length of stay in the ICU (mean difference, −1.78 [95% CI], −2.85 to −0.70] days).

Brushing twice a day versus more frequent intervals was associated with similar effect estimates. The results were consistent in a sensitivity analysis restricted to 7 studies with low risk of bias (1367 patients).

Length of hospital stay outside the ICU and antibiotic use were not associated with tooth brushing.