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Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia

Shi Z, Xie H, Wang P, Zhang Q, Wu Y, Chen E, Ng L, Worthington HV, Needleman I, Furness S
Published Online: 
13 August 2013

Review question

To assess the effects of oral hygiene care on the incidence of ventilator-associated pneumonia (VAP) in critically ill patients receiving mechanical ventilation in intensive care units (ICUs) in hospitals (excluding the use of antibiotics). The aim was to summarise all the available appropriate research in order to facilitate the provision of evidence-based care for these vulnerable patients.

Trials were grouped into four main comparisons.

1. Chlorhexidine antiseptic mouthrinse or gel compared to placebo (treatment without the active ingredient chlorhexidine) or usual care, (with or without toothbrushing).
2. Toothbrushing compared with no toothbrushing, (with or without chlorhexidine).
3. Powered compared with manual toothbrushing.
4. Oral care with other solutions.

Background

Critically ill people, who may be unconscious or sedated while they are treated in intensive care units often need to have machines to help them breathe (ventilators). The use of these machines for more than 48 hours may result in VAP. VAP is a potentially serious complication in these patients who are already critically ill.

Keeping the teeth and the mouth clean, preventing the build-up of plaque on the teeth, or secretions in the mouth may help reduce the risk of developing VAP. Oral hygiene care, using a mouthrinse, gel, toothbrush, or combination, together with aspiration of secretions may reduce the risk of VAP in these patients.

Study characteristics

This review of existing studies was carried out by the Cochrane Oral Health Group and the evidence is current up to 14 January 2013.

Thirty-five separate research studies were included but only a minority (14%) of the studies were well conducted and described.

All of the studies took place in intensive care units in hospitals. In total there were 5374 participants randomly allocated to treatment. Participants were critically ill and required assistance from nursing staff for their oral hygiene care. In three of the included studies participants were children and in the remaining studies only adults participated. Participants had been hospitalised as medical, surgical or trauma patients. In 13 studies it was not clear which of these three categories the participants belonged to.

Key results

Effective oral hygiene care is important for ventilated patients in intensive care. We found evidence that chlorhexidine either as a mouthrinse or a gel reduces the odds of VAP in adults by about 40%. So for example for every 15 people on ventilators in intensive care, the use of oral hygiene care including chlorhexidine will prevent one person developing VAP. However, we found no evidence that chlorhexidine makes a difference to the numbers of patients who die in ICU, to the number of days of mechanical ventilation or the number of days in ICU.

The three studies of children (aged birth to 15 years) showed no evidence of a difference in VAP between the use of chlorhexidine mouthrinse or gel and placebo in children.

Four studies showed no evidence of a difference between toothbrushing (with or without chlorhexidine) and oral care without toothbrushing (with or without chlorhexidine) in the risk of developing VAP. Two studies showed some evidence of a reduction in VAP with povidone iodine antiseptic mouthrinse.

There was not enough research information available to provide evidence of the effects of other mouth care rinses such as water, saline or triclosan.

Only two of the included studies reported any adverse effects of the interventions (mild oral irritation (one study) and unpleasant taste (both chlorhexidine and placebo)), four studies reported that there were no adverse effects and the remaining studies do not mention adverse effects in the reports.

Quality of the evidence

The evidence presented is of moderate quality. Only 14% of the studies were well conducted and described.

This record should be cited as: 
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
Assessed as up to date: 
14 January 2013