We have previously looked at a review and a number of studies addressing the issue of oral hygiene and ventilator-associated pneumonia (VAP) and (Dental Elf May 20th 2013). A new Cochrane review has just been published which aimed to assess the effects of oral hygiene care (OHC) on the incidence of VAP in critically ill patients receiving mechanical ventilation in intensive care units (ICUs) in hospitals.
A detailed search of a wide range of databases was undertaken. This included, CENTRAL, Cochrane Oral Health Group’s Trials Register. Medline, Embase, CINHAL, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, Wan Fang Database, OpenGrey and ClinicalTrials.gov. The review included randomised controlled trials (RCTs) for all oral hygiene care interventions. Previous reviews have considered toothbrushing and chlorhexidine. Cochrane usual robust methodological approach was taken.
- The review included 35 RCTs (5374 participants). The majority (17 studies) were considered to be at high risk of bias, 13 had unclear risk of bias and 5 a low risk of bias.
- There was moderate evidence that Chlorhexidine (CHX) mouthrinse or gel as part of OHC was associated with a reduction in VAP (OR 0.60, 95% confidence intervals (CI) 0.47 to 0.77, P < 0.001, I2 = 21%). This equates to a number needed to treat (NNT) of 15 (95% CI 10-34), that is, 15 ventilated patients need to have OHC with chlorhexidine to prevent one outcome of VAP.
- There was no evidence of difference between CHX and placebo/usual care and mortality (OR 1.10, 95% CI 0.87 to 1.38) duration of mechanical ventilation (MD 0.09, 95% CI -0.84 to 1.01 days) or duration of ICU stay ((MD -0.21, 95% CI -1.48 to 1.89 days).
- 4 RCTs (828 participants) compared OHC with toothbrushing against no toothbrushing and there was no evidence of a difference in VAP (OR 0.69, 95% CI 0.36 to 1.29) or mortality (OR 0.85, 95% CI 0.62 to 1.16).
The authors’ concluded
Effective OHC is important for ventilated patients in intensive care. OHC that includes either chlorhexidine mouthwash or gel is associated with a 40% reduction in the odds of developing ventilator-associated pneumonia in critically ill adults. However, there is no evidence of a difference in the outcomes of mortality, duration of mechanical ventilation or duration of ICU stay. There is no evidence that OHC including both CHX and toothbrushing is different from OHC with CHX alone, and some weak evidence to suggest that povidone iodine mouthrinse is more effective than saline in reducing VAP. There is insufficient evidence to determine whether powered toothbrushing or other oral care solutions are effective in reducing VAP.
The review shows that the use of chlorhexidine as part of oral hygiene can in ICU reduce the incidence of VAP by about 40% there was no evidence of a reduction in mortality and as the reviews discussion notes there is some debate about the mortality attributable to VAP which may be in the order of 1% on day 30 which may help explain the findings.
Shi Z, Xie H, Wang P, Zhang Q, Wu Y, Chen E, Ng L, Worthington HV, Needleman I, Furness S. Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD008367. DOI: 10.1002/14651858.CD008367.pub2.