International Journal of Nursing Studies 52 (2015) 452–464
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International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns
Review
Prophylactic oral health procedures to prevent hospital-acquired and ventilator-associated pneumonia: A systematic review Mohamed El-Rabbany a, Noha Zaghlol b, Mohit Bhandari c, Amir Azarpazhooh a,d,e,f,* a
Faculty of Dentistry, University of Toronto, Toronto, ON, Canada School of Nursing, Faculty of Health Sciences, Ottawa University, Ottawa, ON, Canada Department of Surgery and Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada d Department of Dentistry, Mount Sinai Hospital, Toronto, ON, Canada e Clinical Epidemiology Program, Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, ON, Canada f Toronto Health Economics and Technology Assessment Collaborative, University of Toronto, Toronto, ON, Canada b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 25 March 2014 Received in revised form 16 July 2014 Accepted 18 July 2014
Objectives: Given the severity of hospital-acquired pneumonia and ventilator-associated pneumonia, the purpose of this systematic review was to identify various oral health procedures, in intensive care unit or nursing home setting, shown to help reduce the incidence of hospital-acquired and ventilator-associated pneumonia. Design: Randomized controlled trials evaluating the efficacy of at least one prophylactic oral health procedure in reducing hospital-acquired pneumonia or ventilator-associated pneumonia were included. Data sources: MEDLINE, EMBASE, and CINAHL were searched for relevant studies. In addition, references of studies included for full-text review were examined for potentially relevant studies. Grey literature was searched for by reviewing the first 200 results obtained in Google ScholarTM. Review methods: Two authors conducted study selection and data extraction for this review. The Cochrane risk of bias tool was applied to assess the quality of the included trials (namely sequence generation, allocation concealment, blinding, the completeness of data assessment, the lack of selective reporting, and the lack of other miscellaneous biases) based on the information in the original publications. An assessment of a high, unclear, or low risk of bias was assigned to each domain. Results: Through review of the 28 trials included in this review, we found that good oral health care was suggested to be associated with a reduction in the risk for hospitalacquired and ventilator-associated pneumonia in high-risk patients. Furthermore, through the review of studies evaluating the efficacy of chlorhexidine, we found that, despite the presence of mixed results, that chlorhexidine may be a particularly effective means of lowering the risk for hospital-acquired and ventilator-associated pneumonia. The efficacy of other prophylactic oral health techniques such as the use of tooth brushing or iodine swab was uncertain.
Keywords: Aspiration pneumonia Dentistry Hospital-acquired pneumonia Oral health Oral prophylaxis Ventilator-associated pneumonia
* Corresponding author at: Faculty of Dentistry, University of Toronto, Disciplines of Endodontics and Dental Public Health, 515-C, 124 Edward Street, Toronto, ON, Canada M5G 1G6. Tel.: +1 416 979 4900x4429; fax: +1 416 979 4936. E-mail address: [email protected] (A. Azarpazhooh). http://dx.doi.org/10.1016/j.ijnurstu.2014.07.010 0020-7489/ß 2014 Elsevier Ltd. All rights reserved.
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Conclusions: Current evidence suggests that chlorhexidine rinses, gels and swabs may be effective oral disinfectants in patients at high risk for hospital-acquired and ventilatorassociated pneumonia. The evidence supporting the effectiveness of other oral care means still remains scarce and methodologically weak. As such, efforts to promote the increase of high-quality studies and to support nursing educational efforts to promote the dissemination of evidence-based knowledge of oral prophylaxis into clinical practice are warranted. ß 2014 Elsevier Ltd. All rights reserved.
What is already known about this topic? A review by our team in 2006 indicated that though there is some evidence to demonstrate the effectiveness of oral prophylactic measures in preventing hospital-acquired and ventilator-associated pneumonia. Nevertheless, the evidence was found to be weak, indicating a need to update the review. What does this paper add? This paper serves as an update to our previous systematic review in 2006. Through this review, we found that the current evidence suggests that chlorhexidine rinses, gels and swabs may be effective oral disinfectants in patients at high risk for hospital-acquired and ventilator-associated pneumonia. 1. Background Since the release of the United States Surgeon General’s Report at the start of the millennium, there has been a rise in the interest to determine the relationship between oral health and various systemic diseases (U.S. Department of Health and Human Services, 2000). One such area that has been of interest to dentists and nurses alike has been the connection between oral health and respiratory disease, with a focus on hospital-acquired pneumonia. Pneumonia, an acute illness, is defined by the Centers for Disease Control and Prevention (2014) as ‘‘an infection of the lungs that can cause mild to severe illness in people of all ages’’. Reported to be responsible for approximately 15% of all hospital-acquired infections and 13–48% of nursing home-associated infections, hospital-acquired pneumonia is the second most common nosocomial infection immediately following urinary tract infections, and accounts for 20–33% attributable mortality rates (Coffin et al., 2008; Healthcare Infection Control Practices Advisory Committee, 2004). As with most nosocomial infections, hospital-acquired pneumonia is reported to occur more frequently among high-risk individuals including patients within the extremes of age or have a severe underlying disease (Healthcare Infection Control Practices Advisory Committee, 2004). There are four possible routes of contamination of the lower airways by microorganisms: (1) through aspiration of food, oropharyngeal secretions, or gastric contents, (2) through spread of infections from contagious sites, (3) through inhalation of infectious aerosols; or (4) through hematogenous spread from extrapulmonary sources of
infection (Taylor et al., 2000). Nonetheless, aspiration of colonized secretions from the oropharynx into the upper airway remains to be the primary mechanism by which microorganisms (such as Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus and Enterobacter) enter the lungs (Amin et al., 2004; Marik, 2001). Patients within an Intensive Care Unit who require mechanical ventilation are especially susceptible to acquiring pneumonia (Leroy and Soubrier, 2004). Onsets of pneumonia as a consequence of mechanical ventilation are commonly referred to as ventilator-associated pneumonia. Even with adequate treatment, ventilator-associated pneumonia is associated with high morbidity and mortality rates, conferring mortality rates of over 10% (Coffin et al., 2008). In Canada, there are approximately 4000 cases of ventilator-associated pneumonia reported annually, resulting in an average of 230 deaths per year (Muscedere et al., 2008). The incidence of ventilatorassociated pneumonia is 10.6 cases per 1000 ventilator days, with an average increase in intensive care unit stay of 4.3 days (Muscedere et al., 2008). Accounting for approximately 17,000 intensive care unit days per year, it is estimated that ventilator-associated pneumonia in turn is responsible for nearly $46 million per year in inpatient costs (Muscedere et al., 2008). In 2006, our team performed a systematic review to examine the evidence regarding an etiological association between oral health indicators and pneumonia or other respiratory diseases (Azarpazhooh and Leake, 2006). Searching for studies published in 2005 or earlier, they identified 10 clinical trials evaluating the effectiveness of prophylactic oral health procedures in reducing the progression of occurrence of pneumonia. Of the 10 included studies, 7 were randomized controlled trials (RCTs) and 3 were nonrandomized trials. Though they were unable to pool the included studies’ results in a meaningful manner due to the large variation in the methodologies of the included studies, they were able to provide data supporting a positive association between improved oral health and the reduction in the progression or occurrence of respiratory diseases among high-risk patients in intensive care units and nursing homes. Given the significant negative impact of hospitalacquired and ventilator-associated pneumonia on the health care system, this review aimed to (1) update our previous systematic review and review the most recent evidence to further verify the reversibility between poor oral health and pneumonia, and (2) to identify various oral health techniques shown to help reduce the incidence of hospitalacquired pneumonia and ventilator-associated pneumonia.
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2. Methods
Disagreements between the two authors were resolved by consensus.
2.1. Study eligibility criteria 2.4. Data extraction In a manner similar to that of our original review (Azarpazhooh and Leake, 2006), the inclusion criterion for studies in this review was that they evaluated the efficacy of at least one prophylactic oral health procedure in preventing hospital-acquired or ventilator-associated pneumonia in a hospital or long-term care setting. The search was limited to RCTs because they provide the highest level of evidence for determining reversibility (i.e., a reduction in exposure is followed by lower rates of disease (Fletcher and Fletcher, 2005). Having already included all relevant studies identified in our previous review, the search was restricted to studies published during or after 2005. All non-English studies and studies not available through the University of Toronto holdings were excluded from review. 2.2. Search strategy In comparison to our previous review (Azarpazhooh and Leake, 2006), only high-yield databases were searched for relevant studies. A similar search to our previous review was applied electronically through the following bibliographic databases at the University of Toronto: Medline (OVID Medline: 2005-August Week 1 2013 and OVID Medline: In Process and Other Non-Indexed Citations), EMBASE (OVID Embase Classic + Embase 2005 to 2013 Week 31), and Cumulative Index to Nursing & Allied Health Literature (CINAHL; dating from 2005 to August 2013). In addition, references of studies included for fulltext review were examined for potentially relevant studies. Grey literature was searched for by reviewing the first 200 results obtained in Google ScholarTM. A sample detailed search used for Medline was as follows: (1) ventilator-associated pneumonia.mp. or exp Pneumonia, Ventilator-Associated/ (2) aspiration pneumonia.mp. or exp Pneumonia, Aspiration/ (3) 1 or 2 (4) exp Dental Care/or exp Oral Hygiene/or exp Oral Health/ (5) exp Dentistry/ (6) oral health.mp. (7) 4 or 5 or 6 (8) 3 and 7 (9) limit 9 to yr = ‘‘2006–Current’’
2.3. Study selection Study selection for this review was conducted by one author (ME) and reviewed by a senior author (AA). Following the removal of duplicate studies within the full yield of the initial search, potentially eligible articles were firstly identified by their titles or abstracts. Trials deemed to be potentially eligible were subsequently reviewed through the full-text stage to determine final eligibility.
Data extraction of the included studies was conducted by the primary author (ME) and reviewed by the senior author (AA). The following information was collected from each of the included studies: sample size, country in which the study was conducted, setting of the study, intervention(s), control procedures, outcome measures (including the relative risks with 95% confidence intervals and statistical significance), and the presence of potential conflicts of interest. All collected data was stored in a Microsoft ExcelTM file. 2.5. Validity assessment The Cochrane risk of bias tool (Higgins et al., 2011) was applied to assess the quality of the included trials based on the information in the original publications. Through this tool, six domains were evaluated, namely sequence generation, allocation concealment, blinding (requiring at least double blinding), the completeness of data assessment, the lack of selective reporting (requiring the trial to have been registered a priori), and the lack of other miscellaneous biases (such as the lack of treatment calibration, a sample size below 20, and a lack of reporting of baseline characteristics). An assessment of a high, unclear, or low risk of bias was assigned to each domain. Using this information, studies were given an overall assessment of their risk of bias where ‘‘low risk of bias’’ corresponded to having no less than 5 domains with a low risk of bias, ‘‘medium risk of bias’’ corresponded to having 3–4 domains with a low risk of bias, and ‘‘high risk of bias’’ corresponded to studies having 2 or less domains with a low risk of bias). 2.6. Synthesis No meta-analyses were attempted given the expected methodological heterogeneity between studies. 3. Results From the initial 911 studies provided by the search, 412 remained after duplicate removal. Of these, 19 additional RCTs were identified. An additional 2 RCTs were identified on the recommendation of an expert reviewer, and along with the addition of the 7 RCTs included in our previous review (Azarpazhooh and Leake, 2006), the total number of included trials was brought up to 28 (Fig. 1). A total of seven studies were excluded at the full-text review stage, with reasons for exclusion (Table 1). Overall, the interventions studied within the included trials were as follows: (1) professional dental care (Adachi et al., 2002); (2) sodium bicarbonate mouthrinse (Bellissimo-Rodrigues et al., 2009); (3) Toothbrushing (Bopp et al. (2006); Kusahara et al., 2012; Munro et al., 2009; Pobo et al., 2009; Prendergast et al., 2012; Yao et al., 2011); (4) chlorhexidine (Bellissimo-Rodrigues et al., 2009; Berry et al., 2011; Bopp
Idenficaon
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Records idenfied through database searching (n = 711)
455
Addional records idenfied through other sources (n = 200)
Eligibility
Screening
Records aer duplicates removed (n = 412)
Records screened (n = 412)
Records excluded (n = 386)
Full-text arcles assessed for eligibility (n = 26)
Full-text arcles excluded, with reasons (n = 7)
Included
Arcles added from previous review (n = 7) and on the recommendaon of expert reviewers (n = 2)
Studies included in qualitave synthesis (n = 28) Fig. 1. Flow chart summarizing the article screening process.
et al., 2006; C´abov et al., 2010; DeRiso et al., 1996; Fourrier et al., 2005, 2000; Grap et al., 2011; Houston et al., 2002; Jacomo et al., 2011; Koeman et al., 2006; Kusahara et al., ¨ zc¸aka 2012; Lorente et al., 2012; Meinberg et al., 2012; O et al., 2012; Panchabhai et al., 2009; Scannapieco et al., 2009; Sebastian et al., 2012; Segers et al., 2006; Seguin et al., 2006; Tantipong et al., 2008); (5) topical application of a non-absorbable antibiotic solution (150 mg polymyxin B sulfate, 1 g neomycin sulfate and 1 g vancomycin hydrochloride) (Pugin et al., 1991); and (6) povidine iodine swab (Seguin et al., 2006; Yoneyama et al., 2002). Of the 28 trials included, 26 were short-term studies in an intensive care unit setting and 2 were long-term studies that took place in a nursing home (Adachi et al., 2002; Table 1 List of excluded studies and the reasons for their exclusion. Excluded study
Reason for exclusion
Caruso et al. (2009)
Interventions of interest not evaluated Not RCT Not RCT Not RCT Not RCT Outcomes of interest not evaluated Not RCT
Ferozali et al. (2007) Fields (2008) McCoy et al. (2012) Mori et al. (2006) Needleman et al. (2011) Ross and Crumpler (2007)
Yoneyama et al., 2002). The median number of patients included in the studies was 228, with sample size values ranging from 5 to 991. Almost all included patients were adults, with only three studies focusing on oral health intervention effects specifically pertaining to children (Houston et al., 2002; Koeman et al., 2006; Sebastian et al., 2012). Details regarding the methodologies of the included trials are summarized in Tables 2 and 3, with primary outcome data summarized in Fig. 2. An analysis of the included studies revealed that many possessed methodological flaws, resulting in an increased potential for bias (Fig. 3). Overall, quality of the included studies ranged from low to high risk of bias, with 12 studies having a high risk of bias, 12 studies having a medium risk of bias, and only 4 studies rated to have low risks of bias. Of the six domains evaluated by the Cochrane risk of bias tool, only 7 studies were reported to be free of selective reporting, with the remaining studies evaluated as having an unclear risk of bias in this domain due to that they failed to definitively prove that they had not changed their protocols in an ad hoc manner. Moreover, only 5 of the included studies reported having adequate allocation concealment methods. For the remaining risk of bias domains, 15 trials were evaluated to have had adequate sequence generation procedures, 14 had adequate blinding methods, 19 did not have a significant loss to follow-up of patients, and 12 were evaluated to be free of other
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Table 2 A summary of the characteristics and results of the included studies evaluating the rates of hospital-acquired pneumonia. Author, date
Population
Intervention
Control treatment
Outcome
Potential conflicts of interest?
Overall risk of bias?
Chlorhexidine
BellissimoRodrigues et al. (2009)
198 Patients in an intensive care unit in Brazil with an expected duration of >48 h. Only 133 patients were on mechanical ventilation 60 Patients (40 on ventilation) in an intensive care unit in Croatia, with a minimum stay of three days.
N = 98 (64 on ventilation) Mean age: 62.5 (17–89) 47% male Intervention: 0.12% chlorhexidine and brushing 3 times/day N = 30 Mean age: 57 16 63% male Intervention: standard oral care (rinsing mouth with bicarbonate isotonic serum followed by oropharyngeal sterile aspiration) and 0.2% chlorhexidine gel, 3 times/day N = 173 Mean age: 64.1 0.7 69% male Intervention: 0.12% chlorhexidine gluconate oral rinse N = 30 Mean age: 51.2 15.2 63% male Intervention: dental plaque decontamination with 0.2% chlorhexidine gel, 3 times a day
N = 96 (69 on ventilation) Mean age: 54 (15–85) 51% male Intervention: brushing and placebo rinse 3 times/ day N = 30 Mean age: 52 19 67% male Intervention: standard oral care (rinsing mouth with bicarbonate isotonic serum followed by oropharyngeal sterile aspiration)
Rates of respiratory infections and ventilatorassociated pneumonia were similar between the two groups
No
Medium
Significantly fewer pneumonia cases were reported in the intervention group
No
Medium
N = 180 Mean age: 63.5 0.8 68% male Intervention: placebo rinse
The intervention group had significantly lower pneumonia rates
Not reported
Medium
N = 30 Mean age: 50.4 15.5 63% male Intervention: standard oral care (mouth rinsing with bicarbonate isotonic serum followed by suctioning 4X/ day N = 291 79% male Intervention: phenolic mixture twice daily postoperatively for 10 days or until extubation N = 247 Mean age: 36.9 16.2 69% male Intervention: Oral and pharyngeal suction followed by oral saline swab, twice daily N = 469 Mean age: 66.4 9.9 74% male Intervention: 0.12% chlorhexidine rinse/nasal ointment, 4 times/day
The intervention group had significantly lower pneumonia rates than the control group
Not reported
Medium
No significant differences in the rates of pneumonia between the two groups
No
High
No significant differences in the incidence of pneumonia were found
No
High
The incidence of pneumonia was significantly lower in the treatment group
No
Medium
C´abov et al. (2010)
DeRiso et al. (1996)
Fourrier et al. (2000)
353 Patients in an intensive care unit in the USA undergoing coronary artery bypass grafting, valve, or other open-heart surgical procedures. 60 Patients in an intensive care unit in France with a 5-day stay recommendation, requiring mechanical ventilation.
Houston et al. (2002)
561 Patients in an intensive care unit in the USA, requiring intubation.
Panchabhai et al. (2009)
512 Patients in an intensive care unit in India, 171 of which required mechanical ventilation.
Segers et al. (2006)
991 Patients in an intensive care unit in the Netherlands, following cardiac surgery.
N = 270 70% male Intervention: 0.12% chlorhexidine rinse twice daily postoperatively for 10 days or until extubation N = 224 Mean age: 35.2 15.9 61% male Intervention: Oral and pharyngeal suction followed by 0.2% chlorhexidine oral swab, twice daily N = 485 Mean age: 65.3 10.4 74% male Intervention: 0.12% chlorhexidine rinse/nasal ointment, 4 times/day
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Treatment
High Not reported The treatment group group had significantly less case counts of fevers and deaths due to aspiration pneumonia Adachi et al. (2002) Toothbrushing
141 Patients requiring daily care in two nursing homes in Japan.
N = 40 Intervention: Scaling and brushing with an electric brush, an interdental brush, and a sponge brush, once weekly
High Not reported No significant differences in the incidence of pneumonia between the two groups
N=3 Mean age: 73.7 (62–81) 67% male Intervention: suctioning soft foam swab and half strength hydrogen peroxide, 6 times/day N = 48 Intervention: basic oral hygiene consisting of mainly swabbing with a sponge brush and denture cleaning Bopp et al. (2006) Chlorhexidine + toothbrushing
5 Patients in a critical care unit in the USA, requiring intubation.
N=2 Mean age: 40 (28–52) 0% male Intervention: 0.12% chlorhexidine plus tooth brushing 2 times/day
Overall risk of bias? Potential conflicts of interest? Outcome Author, date Treatment
Table 2 (Continued )
Population
Intervention
Control treatment
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miscellaneous biases. No attempts were made to contact authors to inquire on methodological issues that were not clearly reported. Despite the heterogeneity between studies regarding their interventions and settings, the general trend amongst the included studies suggested a correlation between good oral care and lower rates of hospitalacquired pneumonia (Tables 2 and 3). Of the studies examining the effects of chlorhexidine rinse or gel, only 7 of the studies were able to demonstrate a positive significant effect in lowering the risk of hospital-acquired/ ventilator-associated pneumonia in patients. In the 13 studies that did not suggest a significant effect of chlorhexidine, the effects have been hypothesized to be masked by the fact that tooth brushing presented as a potential confounder in a number of the studies (Berry et al., 2011), or that not enough statistical power was available (Fourrier et al., 2005). The effects of tooth brushing on pneumonia rates, reviewed by six studies, was only demonstrated to be effective in one of the studies, while it was suggested in the other five studies to only have a significant effect on plaque level reduction. The effects of professional oral health cleaning, antibiotic solution, povidine iodine swab, and sodium bicarbonate rinse on pneumonia rates were studied by 1–2 studies each, with only the first three interventions found to be significantly effective in lowering pneumonia rates. 4. Discussion The purpose of this systematic review was to find evidence to demonstrate reversibility between oral health and pneumonia, and to identify effective prophylactic oral health procedures for the prevention of hospital-acquired and ventilator-associated pneumonia. Given the large amount of heterogeneity between the included studies, we felt it inappropriate to amalgamate the results of the included studies, which in turn limited our ability to draw sound conclusions. Nevertheless, through a review of the overall trend presented within current evidence it can be deduced that, as was reported by Azarpazhooh and Leake (2006), the use of oropharyngeal decontamination using various antimicrobial interventions will likely result in a risk reduction in the progression and occurrence of respiratory diseases, specifically pertaining to hospitalacquired respiratory infections among high-risk populations. By reviewing the evidence we have presented a number of interventions proposed as being effective means of reducing the risk of acquiring pneumonia in an intensive care unit or nursing home setting. Though a number of studies implied that there might be a significant effect with the use of chlorhexidine in its ability to reduce the risk of acquiring hospital-acquired and ventilator-associated pneumonia, it is nevertheless important to note that twelve of the seventeen studies reviewing the efficacy of chlorhexidine failed to demonstrate a significant effect. A few points of consideration come to mind when evaluating these studies: firstly, it should be noted that 7 of the 13 studies that failed to show a significant effect possessed
458
Table 3 A summary of the characteristics and results of the included studies evaluating the rates of ventilator-associated pneumonia. Author, date
Population
Intervention
Control treatment
Outcome
Potential conflicts of Interest?
Overall risk of bias?
Antibiotic Rinse
Pugin et al. (1991)
52 Patients in an intensive care unit in Switzerland, dependent on a ventilator.
N = 27 Mean age: 46 20 74% male Intervention: topical application of placebo solution.
Incidence of ventilator-associated pneumonia was significantly less in the treatment group than the control group.
Not reported
High
Chlorhexidine
BellissimoRodrigues et al. (2009)
198 Patients in an intensive care unit in Brazil with an expected duration of >48 h. Only 133 patients were on mechanical ventilation. 109 Patients in an intensive care unit in Australia with an expected duration of >48 h on mechanical ventilation.
N = 25 Mean age: 45 20 76% male Intervention: topical application of a solution of polymixin B sulfate, neomycin sulfate, and vancomycin (PNV). N = 98 (64 on ventilation) Mean age: 62.5 (17–89) 47% male Intervention: 0.12% chlorhexidine and brushing 3 times/day.
N = 96 (69 on ventilation) Mean age: 54 (15–85) 51% male Intervention: brushing and placebo rinse 3 times/day.
Rates of respiratory infections and ventilator-associated pneumonia were similar between the two groups.
No
Medium
N = 43 Mean age: 59 18 56% male Intervention: sterile water rinse every 2 h, plus cleaning with toothbrush and toothpaste three times/day.
No significant differences in rates of ventilator-associated pneumonia were found between the three groups.
No
High
N = 114 Mean age: 61.1 14.9 64% male Intervention: decontamination of gingival and dental plaque with a placebo gel three times a day.
No significant differences in nosocomial infection rates were found between the two test groups.
No
Medium
N = 24 46% male Intervention: Usual oral comfort care (details not provided).
No significant differences in the rates of ventilator-associated pneumonia between the two groups.
Not reported
High
N = 73 Mean age: 10.8 months (0–204) 48% male Intervention: Oral care with placebo solution.
No significant differences in the rates of ventilator-associated pneumonia between the two groups.
No
Low
Berry et al. (2011)
Fourrier et al. (2005)
Grap et al. (2011)
Jacomo et al. (2011)
228 Patients in six intensive care units in France requiring endotracheal intubation and mechanical ventilation. Anticipated length of stay was >5 days. 152 Patients in an intensive care unit in the USA requiring endotracheal intubation.
164 Patients in a pediatric intensive care unit in Brazil, some of which required ventilators.
Group A: N = 33 Mean age: 60 18 55% male Intervention: sodium bicarbonate mouthwash every 2 h, plus cleaning with toothbrush and toothpaste three times/day. Group B: N = 33 Mean age: 58 19 51% male Intervention: same as Group B plus 0.2% chlorhexidine gel twice daily. N = 114 Mean age: 61.0 14.7 72.8% male Intervention: antiseptic decontamination of gingival and dental plaque with 0.2% chlorhexidine gel three times a day. N = 36 75% male Intervention: 0.12% chlorhexidine applied by swab at least 12 h prior to intubation, plus usual oral comfort care (details not provided). N = 87 Mean age: 12.2 months (0–176) 48% male Intervention: Oral care with 0.12% chlorhexidine solution.
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Treatment
Koeman et al. (2006)
Meinberg et al. (2012)
¨ zc¸aka et al. O (2012)
96 Patients in a pediatric intensive care unit in Brazil, likely to require ventilation within 24 h of admission. 52 Patients in an intensive care unit in Brazil, requiring ventilation for >72 h. 66 Patients in an intensive care unit in Turkey, expecting to require ventilation for >48 h.
Scannapieco et al. (2009)
175 Patients in an intensive care unit in the USA, expected to be intubated and mechanically ventilated within 48 h of admission.
Sebastian et al. (2012)
86 Patients in a pediatric intensive care unit in India, requiring intubation and mechanical ventilation. 207 Patients in an intensive care unit in Thailand, requiring mechanical ventilation.
Tantipong et al. (2008)
Group A: N = 127 Mean age: 60.9 15.3 56% male Intervention: Oral decontamination with 2% chlorhexidine in Vaseline petroleum jelly four times/day. Group B: N = 128 Mean age: 62.4 19.1 52% male Intervention: Oral decontamination with 2% chlorhexidine and 2% colistin in Vaseline petroleum jelly four times/ day. N = 46 Mean age: 12 50 months 61% male Intervention: Tooth brushing and 0.12% chlorhexidine gel twice daily. N = 28 Mean age: 40.1 14.6 Intervention: 2% chlorhexidine gel plus toothbrushing four times/day N = 32 Mean age: 60.5 14.7 Intervention: 0.2% chlorhexidine oral swab, four times/day. Group A: N = 47 Mean age: 44.8 19.9 74% male Intervention: 0.12% chlorhexidine applied once daily and placebo once daily applied to the oral cavity, and brushing twice daily. Group B: N = 50 Mean age: 47.6 19.1 76% male Intervention: 0.12% chlorhexidine applied twice daily to the oral cavity, along with brushing twice daily. N = 41 Mean age: 3 months to 15 years 56% male Intervention: Suction followed by 1% chlorhexidine gel three times/day. N = 102 Mean age: 56.5 20.1 % male Intervention: 2% chlorhexidine oral rub, tooth brushing, and suctioning of oral secretions, four times/day
N = 130 Mean age: 62.1 15.9 72% male Intervention: Oral decontamination with Vaseline petroleum jelly 4 times/day.
Significantly lower incidence of ventilator-associated pneumonia reported in the treatment groups.
No
Medium
N = 50 Mean age: 34.5 60 months 64% male Intervention: Tooth brushing and placebo gel twice daily. N = 24 Mean age: 41.0 19.0 Intervention: placebo gel plus toothbrushing four times/day N = 34 Mean age: 56 18.2 Intervention: Placebo oral swab, four times/day.
No significant differences in the incidence of ventilator-associated pneumonia were found.
No
Low
No significant differences in the incidence of ventilator-associated pneumonia were found.
No
High
The intervention group had a significantly lower incidence of ventilator-associated pneumonia when compared to the control group. No significant differences in incidence of pneumonia were found between the two groups.
No
Medium
No
Low
No significant differences in incidence of ventilator-associated pneumonia were found between the two groups.
No
Medium
No significant differences in incidence of ventilator-associated pneumonia were found between the two groups.
No
High
N = 49 Mean age: 50 22.5 61% male Intervention: placebo and brushing twice daily.
N = 45 Mean age: 3 months to 15 years 60% male Intervention: Suction followed by placebo gel three times/day. N = 105 Mean age: 60.3 19.1 % male Intervention: Placebo oral rub, tooth brushing, and suctioning of oral secretions, four times/day
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Kusahara et al. (2012)
385 Patients in 5 intensive care units in the Netherlands, requiring mechanical ventilation for >48 h.
459
460
Table 3 (Continued ) Author, date
Population
Intervention
Control treatment
Outcome
Potential conflicts of Interest?
Overall risk of bias?
Iodine
Seguin et al. (2006)
110 Patients in an intensive care unit in France, expected to require mechanical ventilation for >2 days.
N = 31 Mean age: 41 18 64% male Intervention: aspiration of oral secretions every 4 h.
There was a significantly lower incidence of ventilator-associated pneumonia in the iodine treatment group when compared to the other two groups.
No
Medium
Yoneyama et al. (2002)
366 Patients from 11 nursing homes in Japan, followed for two years.
N = 182 Mean age: 82.1 7.5 21% male Intervention: no oral care. some patients performed tooth brushing by themselves once a day or irregularly, but none of them requested oral care from caregivers.
Patients receiving oral care had significantly fewer febrile days, lower pneumonia rates, and fewer deaths due to pneumonia than the control group.
No
High
Lorente et al. (2012)
436 Patients in an intensive care unit in Spain, requiring ventilation for >24 h.
No
Medium
147 Patients intubated for >48 h at an intensive care unit in Spain.
N = 219 Mean age: 60.4 16.6 66% male Intervention: 0.12% chlorhexidine gel only, three times/day. N = 73 Mean age: 52.6 17.2 63% male Intervention: 0.12% chlorhexidine rinse every 8 h.
No significant differences in the incidence of ventilator-associated pneumonia were found.
Pobo et al. (2009)
No significant differences in incidence of ventilator-associated pneumonia were found between the two groups.
No
Low
Prendergast et al. (2012)
78 Patients in an intensive care unit in the USA, intubated within 24 h of admission.
N = 40 Mean age: 51 18.4 58% male Intervention: Standard oral care using manual toothbrush and fluoridated toothpaste, twice daily.
No significant differences in incidence of ventilator-associated pneumonia were found between the two groups.
Not reported
High
Yao et al. (2011)
53 Patients in an intensive care unit in Taiwan, under ventilator support for >48 h.
Group A: N = 36 Mean age: 38 17 74% male Intervention: 10% povidone iodine rinse and aspiration of oral secretions every 4 h Group B: N = 31 Mean age: 38 16 67% male Intervention: saline rinse and aspiration of oral secretions every 4 h. N = 184 Mean age: 82.0 7.8 20% male Intervention: caregivers cleaned patients’ teeth with a toothbrush for 5 minutes or swabbed with povidine iodine (1%) after each meal, plus weekly professional care such as plaque and calculus control as necessary. N = 217 Mean age: 61 15.6 67% male Intervention: 0.12% chlorhexidine gel and toothbrushing, three times/day. N = 74 Mean age: 55.3 17.9 66% male Intervention: electric tooth brushing plus 0.12% chlorhexidine rinse every 8 h. N = 38 Mean age: 54 17.8 50% male Intervention: Tongue scraping and tooth brushing with electric toothbrush with non-foaming toothpaste, twice daily. N = 28 Mean age: 60.7 16.0 61% male Intervention: twice daily tooth brushing with purified water, plus daily oral care using cotton swabs.
N = 25 Mean age: 60.5 16.5 68% male Intervention: daily oral care using cotton swabs.
After 7 days of tooth brushing, the experimental group had significantly lower ventilatorassociated pneumonia rates and better oral health and plaque indices.
No
Medium
Toothbrushing
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Fig. 2. Forest plots summarizing the results of the included studies. Due to the clinical heterogeneity between included studies, data synthesis was precluded.
potential confounding factors, with all 7 studies (including the only three low risk studies evaluating chlorhexidine) providing their control groups with frequent brushing regimens. Secondly, as suggested earlier, given the relatively low sample sizes of the majority of the studies reviewed in this paper, it is likely that many of the studies that failed to demonstrate a significant effect of chlorhexidine on reducing hospital-acquired and ventilator-associated pneumonia risks possessed inadequate power to detect significant differences between the treatment and
control groups, particularly in the study by Bopp et al. (2006), which only possessed a sample size of 5. Thirdly, it should be noted that all but three of the studies reviewing the efficacy of chlorhexidine were rated as having a medium to high risk of bias. Therefore, while it is suggested that chlorhexidine may have a significant effect on reducing the incidence of ventilator-associated and hospital-acquired pneumonia in high-risk populations, caution should be taken when making definitive conclusions regarding its efficacy.
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Fig. 3. A breakdown of the risks of bias of the included studies.
Evidence of the efficacy of tooth brushing to reduce the likelihood of acquiring hospital-acquired or ventilatorassociated pneumonia, when compared to that presented by the studies evaluating chlorhexidine, has not been as well established, with numerous studies suggesting that the short-term effects in reducing risks in intensive care unit patients are negligible. Nevertheless, as expected, tooth brushing was shown in a number of the studies to have a significant effect in reducing plaque levels in patients, and has been suggested to have positive longterm effects in reducing pneumonia risks in individuals in a
nursing home setting. Comparatively, the use of antibiotic rinses or povidine iodine, though proposed to be effective means of reducing hospital-acquired and ventilatorassociated pneumonia infection risks, have only been studied in studies with medium to high risks of bias, and therefore warrant subsequent study before sound conclusions of their efficacies can be made. It should be noted that though all included trials within this report were of a randomized controlled design, the risk of bias evaluation revealed that the majority of the included studies presented with a moderate to high risk of bias. Thus, caution should be taken when translating the recommendations of this study to clinical practice. Efforts should be made to increase the number of low-risk RCTs evaluating the effectiveness of the less established oral health procedures, and updating the recommendations presented in this review as new evidence is made available. Given the intimate role that nurses of all types play in patient health care in intensive care units and nursing homes, nurses present a unique opportunity to help reduce the risks of hospital-acquired or ventilator-associated pneumonia by implementing oral health care practices into routine patient care. As it is intrinsic that the most effective means to ensure the minimization of death tolls and health care costs due to hospital-acquired and ventilator-associated pneumonia is through prevention, it is therefore recommended that nurses integrate the latest evidence-based oral health care procedures into routine patient care protocols, focusing on patients at high risk for acquiring pneumonia. Based on the results of the current review, it is recommended that chlorhexidine rinse or swab be used as a frequent means of oral prophylaxis, given that its efficacy has been reasonably insinuated in the current literature. If the use of chlorhexidine is contraindicated, other means to disinfect the oral cavity, such as tooth brushing, antibiotic rinse, or povidine iodine swab should be used, as is indicated by the best available evidence. It has been suggested that though nurses understand the importance of oral health and hygiene, efforts to translate this knowledge into practice have yet to take full effect. In a recent review of the literature for nursing education, the authors cite the lack of adequate education and guidelines for nurses to be the main cause for the less than optimal oral care practice today (DeKeyser et al., 2009). Further supporting the need for and importance of oral health education for nurses, a study conducted by Tolentino-DelosReyes et al. (2007) was able to demonstrate, as is expected, that nursing education sessions had a significant positive impact on oral hygiene interventions in clinical practice. Given the importance of oral hygiene in helping to prevent ventilator-associated pneumonia among high risk patients established within this and other studies, it is therefore warranted for efforts to be made in expanding the scope of nursing education to stress the importance of applying adequate, evidence-based oral health care in clinical practice, with an emphasis on highrisk patients. Furthermore, efforts to integrate evidencebased oral health recommendations for preventing hospital-acquired and ventilator-associated pneumonia into routine patient care protocol for high-risk patients of
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intensive care units and long-term care facilities, such as those endorsed by this review are recommended. 5. Conclusion Oral health care is presented as a viable method of reducing the risk of acquiring hospital-acquired or ventilator-associated pneumonia in both intensive care unit and long-term care facilities. Though some studies fail to present it’s effectiveness, the efficacy of chlorhexidine rinses, gels, and swabs as a means of disinfecting the oral cavity has been demonstrated in a number of RCTs. Conversely, evidence supporting the effectiveness of other oral care means still remains scarce and methodologically weak. As such, the next requirement is for large, highquality studies to evaluate the effectiveness of the various oral health interventions in helping to reduce the rates of aspiration pneumonia within the vulnerable groups in health care settings, and to support nursing educational efforts to promote the dissemination of this knowledge into clinical practice. Competing interests The authors declare that they have no competing interests. Funding No sources of funding were sought out for the purposes of this review. Ethical approvalNone declared. References Adachi, M., Ishihara, K., Abe, S., Okuda, K., Ishikawa, T., 2002. Effect of professional oral health care on the elderly living in nursing homes. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 94, 191–195. Amin, A.N., Feinbloom, D., Krekun, S., Li, J., Pak, M., et al., 2004. Recommendations for management of community- and hospital-acquired pneumonia—the hospitalist perspective. Curr. Opin. Pulm. Med. 10, S23–S27. Azarpazhooh, A., Leake, J.L., 2006. Systematic review of the association between respiratory diseases and oral health. J. Periodontol. 77, 1465–1482. Bellissimo-Rodrigues, F., Bellissimo-Rodrigues, W.T., Viana, J.M., Gil Cezar Alkmim Teixeira, M.D., Nicolini, E., et al., 2009. Effectiveness of oral rinse with chlorhexidine in preventing nosocomial respiratory tract infections among intensive care unit patients. Infect. Control Hosp. Epidemiol. 30 (10), 952–958. Berry, A.M., Davidson, P.M., Masters, J., Rolls, K., Ollerton, R., 2011. Effects of three approaches to standardized oral hygiene to reduce bacterial colonization and ventilator associated pneumonia in mechanically ventilated patients: a randomized control trial. Int. J. Nurs. Stud. 48, 681–688. Bopp, M., Darby, M., Loftin, K.C., Broscious, S., 2006. Effects of daily oral care with 0.12% chlorhexidine gluconate and a standard oral care protocol on the development of nosocomial pneumonia in intubated patients: a pilot study. J. Dent. Hyg. 80 (3), 9. C´abov, T., Macan, D., Husedzˇinovic´, I., Sˇkrlin-Sˇubic´, J., Bosˇnjak, D., et al., 2010. The impact of oral health and 0.2% chlorhexidine oral gel on the prevalence of nosocomial infections in surgical intensive-care patients: a randomized placebo-controlled study. Wien. Klin. Wochenschr. 122 (13–14), 397–404. Caruso, P., Denari, S., Ruiz, S.A., Demarzo, S.E., Deheinzelin, D., 2009. Saline instillation before tracheal suctioning decreases the incidence of ventilator-associated pneumonia. Crit. Care Med. 37 (1), 32–38. Centers for Disease Control and Prevention, 2014. Pneumonia http:// www.cdc.gov/pneumonia/ (accessed 7/2/2014).
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Contents lists available at ScienceDirect
International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns
Review
Prophylactic oral health procedures to prevent hospital-acquired and ventilator-associated pneumonia: A systematic review Mohamed El-Rabbany a, Noha Zaghlol b, Mohit Bhandari c, Amir Azarpazhooh a,d,e,f,* a
Faculty of Dentistry, University of Toronto, Toronto, ON, Canada School of Nursing, Faculty of Health Sciences, Ottawa University, Ottawa, ON, Canada Department of Surgery and Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada d Department of Dentistry, Mount Sinai Hospital, Toronto, ON, Canada e Clinical Epidemiology Program, Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, ON, Canada f Toronto Health Economics and Technology Assessment Collaborative, University of Toronto, Toronto, ON, Canada b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 25 March 2014 Received in revised form 16 July 2014 Accepted 18 July 2014
Objectives: Given the severity of hospital-acquired pneumonia and ventilator-associated pneumonia, the purpose of this systematic review was to identify various oral health procedures, in intensive care unit or nursing home setting, shown to help reduce the incidence of hospital-acquired and ventilator-associated pneumonia. Design: Randomized controlled trials evaluating the efficacy of at least one prophylactic oral health procedure in reducing hospital-acquired pneumonia or ventilator-associated pneumonia were included. Data sources: MEDLINE, EMBASE, and CINAHL were searched for relevant studies. In addition, references of studies included for full-text review were examined for potentially relevant studies. Grey literature was searched for by reviewing the first 200 results obtained in Google ScholarTM. Review methods: Two authors conducted study selection and data extraction for this review. The Cochrane risk of bias tool was applied to assess the quality of the included trials (namely sequence generation, allocation concealment, blinding, the completeness of data assessment, the lack of selective reporting, and the lack of other miscellaneous biases) based on the information in the original publications. An assessment of a high, unclear, or low risk of bias was assigned to each domain. Results: Through review of the 28 trials included in this review, we found that good oral health care was suggested to be associated with a reduction in the risk for hospitalacquired and ventilator-associated pneumonia in high-risk patients. Furthermore, through the review of studies evaluating the efficacy of chlorhexidine, we found that, despite the presence of mixed results, that chlorhexidine may be a particularly effective means of lowering the risk for hospital-acquired and ventilator-associated pneumonia. The efficacy of other prophylactic oral health techniques such as the use of tooth brushing or iodine swab was uncertain.
Keywords: Aspiration pneumonia Dentistry Hospital-acquired pneumonia Oral health Oral prophylaxis Ventilator-associated pneumonia
* Corresponding author at: Faculty of Dentistry, University of Toronto, Disciplines of Endodontics and Dental Public Health, 515-C, 124 Edward Street, Toronto, ON, Canada M5G 1G6. Tel.: +1 416 979 4900x4429; fax: +1 416 979 4936. E-mail address: [email protected] (A. Azarpazhooh). http://dx.doi.org/10.1016/j.ijnurstu.2014.07.010 0020-7489/ß 2014 Elsevier Ltd. All rights reserved.
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Conclusions: Current evidence suggests that chlorhexidine rinses, gels and swabs may be effective oral disinfectants in patients at high risk for hospital-acquired and ventilatorassociated pneumonia. The evidence supporting the effectiveness of other oral care means still remains scarce and methodologically weak. As such, efforts to promote the increase of high-quality studies and to support nursing educational efforts to promote the dissemination of evidence-based knowledge of oral prophylaxis into clinical practice are warranted. ß 2014 Elsevier Ltd. All rights reserved.
What is already known about this topic? A review by our team in 2006 indicated that though there is some evidence to demonstrate the effectiveness of oral prophylactic measures in preventing hospital-acquired and ventilator-associated pneumonia. Nevertheless, the evidence was found to be weak, indicating a need to update the review. What does this paper add? This paper serves as an update to our previous systematic review in 2006. Through this review, we found that the current evidence suggests that chlorhexidine rinses, gels and swabs may be effective oral disinfectants in patients at high risk for hospital-acquired and ventilator-associated pneumonia. 1. Background Since the release of the United States Surgeon General’s Report at the start of the millennium, there has been a rise in the interest to determine the relationship between oral health and various systemic diseases (U.S. Department of Health and Human Services, 2000). One such area that has been of interest to dentists and nurses alike has been the connection between oral health and respiratory disease, with a focus on hospital-acquired pneumonia. Pneumonia, an acute illness, is defined by the Centers for Disease Control and Prevention (2014) as ‘‘an infection of the lungs that can cause mild to severe illness in people of all ages’’. Reported to be responsible for approximately 15% of all hospital-acquired infections and 13–48% of nursing home-associated infections, hospital-acquired pneumonia is the second most common nosocomial infection immediately following urinary tract infections, and accounts for 20–33% attributable mortality rates (Coffin et al., 2008; Healthcare Infection Control Practices Advisory Committee, 2004). As with most nosocomial infections, hospital-acquired pneumonia is reported to occur more frequently among high-risk individuals including patients within the extremes of age or have a severe underlying disease (Healthcare Infection Control Practices Advisory Committee, 2004). There are four possible routes of contamination of the lower airways by microorganisms: (1) through aspiration of food, oropharyngeal secretions, or gastric contents, (2) through spread of infections from contagious sites, (3) through inhalation of infectious aerosols; or (4) through hematogenous spread from extrapulmonary sources of
infection (Taylor et al., 2000). Nonetheless, aspiration of colonized secretions from the oropharynx into the upper airway remains to be the primary mechanism by which microorganisms (such as Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus and Enterobacter) enter the lungs (Amin et al., 2004; Marik, 2001). Patients within an Intensive Care Unit who require mechanical ventilation are especially susceptible to acquiring pneumonia (Leroy and Soubrier, 2004). Onsets of pneumonia as a consequence of mechanical ventilation are commonly referred to as ventilator-associated pneumonia. Even with adequate treatment, ventilator-associated pneumonia is associated with high morbidity and mortality rates, conferring mortality rates of over 10% (Coffin et al., 2008). In Canada, there are approximately 4000 cases of ventilator-associated pneumonia reported annually, resulting in an average of 230 deaths per year (Muscedere et al., 2008). The incidence of ventilatorassociated pneumonia is 10.6 cases per 1000 ventilator days, with an average increase in intensive care unit stay of 4.3 days (Muscedere et al., 2008). Accounting for approximately 17,000 intensive care unit days per year, it is estimated that ventilator-associated pneumonia in turn is responsible for nearly $46 million per year in inpatient costs (Muscedere et al., 2008). In 2006, our team performed a systematic review to examine the evidence regarding an etiological association between oral health indicators and pneumonia or other respiratory diseases (Azarpazhooh and Leake, 2006). Searching for studies published in 2005 or earlier, they identified 10 clinical trials evaluating the effectiveness of prophylactic oral health procedures in reducing the progression of occurrence of pneumonia. Of the 10 included studies, 7 were randomized controlled trials (RCTs) and 3 were nonrandomized trials. Though they were unable to pool the included studies’ results in a meaningful manner due to the large variation in the methodologies of the included studies, they were able to provide data supporting a positive association between improved oral health and the reduction in the progression or occurrence of respiratory diseases among high-risk patients in intensive care units and nursing homes. Given the significant negative impact of hospitalacquired and ventilator-associated pneumonia on the health care system, this review aimed to (1) update our previous systematic review and review the most recent evidence to further verify the reversibility between poor oral health and pneumonia, and (2) to identify various oral health techniques shown to help reduce the incidence of hospitalacquired pneumonia and ventilator-associated pneumonia.
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2. Methods
Disagreements between the two authors were resolved by consensus.
2.1. Study eligibility criteria 2.4. Data extraction In a manner similar to that of our original review (Azarpazhooh and Leake, 2006), the inclusion criterion for studies in this review was that they evaluated the efficacy of at least one prophylactic oral health procedure in preventing hospital-acquired or ventilator-associated pneumonia in a hospital or long-term care setting. The search was limited to RCTs because they provide the highest level of evidence for determining reversibility (i.e., a reduction in exposure is followed by lower rates of disease (Fletcher and Fletcher, 2005). Having already included all relevant studies identified in our previous review, the search was restricted to studies published during or after 2005. All non-English studies and studies not available through the University of Toronto holdings were excluded from review. 2.2. Search strategy In comparison to our previous review (Azarpazhooh and Leake, 2006), only high-yield databases were searched for relevant studies. A similar search to our previous review was applied electronically through the following bibliographic databases at the University of Toronto: Medline (OVID Medline: 2005-August Week 1 2013 and OVID Medline: In Process and Other Non-Indexed Citations), EMBASE (OVID Embase Classic + Embase 2005 to 2013 Week 31), and Cumulative Index to Nursing & Allied Health Literature (CINAHL; dating from 2005 to August 2013). In addition, references of studies included for fulltext review were examined for potentially relevant studies. Grey literature was searched for by reviewing the first 200 results obtained in Google ScholarTM. A sample detailed search used for Medline was as follows: (1) ventilator-associated pneumonia.mp. or exp Pneumonia, Ventilator-Associated/ (2) aspiration pneumonia.mp. or exp Pneumonia, Aspiration/ (3) 1 or 2 (4) exp Dental Care/or exp Oral Hygiene/or exp Oral Health/ (5) exp Dentistry/ (6) oral health.mp. (7) 4 or 5 or 6 (8) 3 and 7 (9) limit 9 to yr = ‘‘2006–Current’’
2.3. Study selection Study selection for this review was conducted by one author (ME) and reviewed by a senior author (AA). Following the removal of duplicate studies within the full yield of the initial search, potentially eligible articles were firstly identified by their titles or abstracts. Trials deemed to be potentially eligible were subsequently reviewed through the full-text stage to determine final eligibility.
Data extraction of the included studies was conducted by the primary author (ME) and reviewed by the senior author (AA). The following information was collected from each of the included studies: sample size, country in which the study was conducted, setting of the study, intervention(s), control procedures, outcome measures (including the relative risks with 95% confidence intervals and statistical significance), and the presence of potential conflicts of interest. All collected data was stored in a Microsoft ExcelTM file. 2.5. Validity assessment The Cochrane risk of bias tool (Higgins et al., 2011) was applied to assess the quality of the included trials based on the information in the original publications. Through this tool, six domains were evaluated, namely sequence generation, allocation concealment, blinding (requiring at least double blinding), the completeness of data assessment, the lack of selective reporting (requiring the trial to have been registered a priori), and the lack of other miscellaneous biases (such as the lack of treatment calibration, a sample size below 20, and a lack of reporting of baseline characteristics). An assessment of a high, unclear, or low risk of bias was assigned to each domain. Using this information, studies were given an overall assessment of their risk of bias where ‘‘low risk of bias’’ corresponded to having no less than 5 domains with a low risk of bias, ‘‘medium risk of bias’’ corresponded to having 3–4 domains with a low risk of bias, and ‘‘high risk of bias’’ corresponded to studies having 2 or less domains with a low risk of bias). 2.6. Synthesis No meta-analyses were attempted given the expected methodological heterogeneity between studies. 3. Results From the initial 911 studies provided by the search, 412 remained after duplicate removal. Of these, 19 additional RCTs were identified. An additional 2 RCTs were identified on the recommendation of an expert reviewer, and along with the addition of the 7 RCTs included in our previous review (Azarpazhooh and Leake, 2006), the total number of included trials was brought up to 28 (Fig. 1). A total of seven studies were excluded at the full-text review stage, with reasons for exclusion (Table 1). Overall, the interventions studied within the included trials were as follows: (1) professional dental care (Adachi et al., 2002); (2) sodium bicarbonate mouthrinse (Bellissimo-Rodrigues et al., 2009); (3) Toothbrushing (Bopp et al. (2006); Kusahara et al., 2012; Munro et al., 2009; Pobo et al., 2009; Prendergast et al., 2012; Yao et al., 2011); (4) chlorhexidine (Bellissimo-Rodrigues et al., 2009; Berry et al., 2011; Bopp
Idenficaon
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Records idenfied through database searching (n = 711)
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Addional records idenfied through other sources (n = 200)
Eligibility
Screening
Records aer duplicates removed (n = 412)
Records screened (n = 412)
Records excluded (n = 386)
Full-text arcles assessed for eligibility (n = 26)
Full-text arcles excluded, with reasons (n = 7)
Included
Arcles added from previous review (n = 7) and on the recommendaon of expert reviewers (n = 2)
Studies included in qualitave synthesis (n = 28) Fig. 1. Flow chart summarizing the article screening process.
et al., 2006; C´abov et al., 2010; DeRiso et al., 1996; Fourrier et al., 2005, 2000; Grap et al., 2011; Houston et al., 2002; Jacomo et al., 2011; Koeman et al., 2006; Kusahara et al., ¨ zc¸aka 2012; Lorente et al., 2012; Meinberg et al., 2012; O et al., 2012; Panchabhai et al., 2009; Scannapieco et al., 2009; Sebastian et al., 2012; Segers et al., 2006; Seguin et al., 2006; Tantipong et al., 2008); (5) topical application of a non-absorbable antibiotic solution (150 mg polymyxin B sulfate, 1 g neomycin sulfate and 1 g vancomycin hydrochloride) (Pugin et al., 1991); and (6) povidine iodine swab (Seguin et al., 2006; Yoneyama et al., 2002). Of the 28 trials included, 26 were short-term studies in an intensive care unit setting and 2 were long-term studies that took place in a nursing home (Adachi et al., 2002; Table 1 List of excluded studies and the reasons for their exclusion. Excluded study
Reason for exclusion
Caruso et al. (2009)
Interventions of interest not evaluated Not RCT Not RCT Not RCT Not RCT Outcomes of interest not evaluated Not RCT
Ferozali et al. (2007) Fields (2008) McCoy et al. (2012) Mori et al. (2006) Needleman et al. (2011) Ross and Crumpler (2007)
Yoneyama et al., 2002). The median number of patients included in the studies was 228, with sample size values ranging from 5 to 991. Almost all included patients were adults, with only three studies focusing on oral health intervention effects specifically pertaining to children (Houston et al., 2002; Koeman et al., 2006; Sebastian et al., 2012). Details regarding the methodologies of the included trials are summarized in Tables 2 and 3, with primary outcome data summarized in Fig. 2. An analysis of the included studies revealed that many possessed methodological flaws, resulting in an increased potential for bias (Fig. 3). Overall, quality of the included studies ranged from low to high risk of bias, with 12 studies having a high risk of bias, 12 studies having a medium risk of bias, and only 4 studies rated to have low risks of bias. Of the six domains evaluated by the Cochrane risk of bias tool, only 7 studies were reported to be free of selective reporting, with the remaining studies evaluated as having an unclear risk of bias in this domain due to that they failed to definitively prove that they had not changed their protocols in an ad hoc manner. Moreover, only 5 of the included studies reported having adequate allocation concealment methods. For the remaining risk of bias domains, 15 trials were evaluated to have had adequate sequence generation procedures, 14 had adequate blinding methods, 19 did not have a significant loss to follow-up of patients, and 12 were evaluated to be free of other
456
Table 2 A summary of the characteristics and results of the included studies evaluating the rates of hospital-acquired pneumonia. Author, date
Population
Intervention
Control treatment
Outcome
Potential conflicts of interest?
Overall risk of bias?
Chlorhexidine
BellissimoRodrigues et al. (2009)
198 Patients in an intensive care unit in Brazil with an expected duration of >48 h. Only 133 patients were on mechanical ventilation 60 Patients (40 on ventilation) in an intensive care unit in Croatia, with a minimum stay of three days.
N = 98 (64 on ventilation) Mean age: 62.5 (17–89) 47% male Intervention: 0.12% chlorhexidine and brushing 3 times/day N = 30 Mean age: 57 16 63% male Intervention: standard oral care (rinsing mouth with bicarbonate isotonic serum followed by oropharyngeal sterile aspiration) and 0.2% chlorhexidine gel, 3 times/day N = 173 Mean age: 64.1 0.7 69% male Intervention: 0.12% chlorhexidine gluconate oral rinse N = 30 Mean age: 51.2 15.2 63% male Intervention: dental plaque decontamination with 0.2% chlorhexidine gel, 3 times a day
N = 96 (69 on ventilation) Mean age: 54 (15–85) 51% male Intervention: brushing and placebo rinse 3 times/ day N = 30 Mean age: 52 19 67% male Intervention: standard oral care (rinsing mouth with bicarbonate isotonic serum followed by oropharyngeal sterile aspiration)
Rates of respiratory infections and ventilatorassociated pneumonia were similar between the two groups
No
Medium
Significantly fewer pneumonia cases were reported in the intervention group
No
Medium
N = 180 Mean age: 63.5 0.8 68% male Intervention: placebo rinse
The intervention group had significantly lower pneumonia rates
Not reported
Medium
N = 30 Mean age: 50.4 15.5 63% male Intervention: standard oral care (mouth rinsing with bicarbonate isotonic serum followed by suctioning 4X/ day N = 291 79% male Intervention: phenolic mixture twice daily postoperatively for 10 days or until extubation N = 247 Mean age: 36.9 16.2 69% male Intervention: Oral and pharyngeal suction followed by oral saline swab, twice daily N = 469 Mean age: 66.4 9.9 74% male Intervention: 0.12% chlorhexidine rinse/nasal ointment, 4 times/day
The intervention group had significantly lower pneumonia rates than the control group
Not reported
Medium
No significant differences in the rates of pneumonia between the two groups
No
High
No significant differences in the incidence of pneumonia were found
No
High
The incidence of pneumonia was significantly lower in the treatment group
No
Medium
C´abov et al. (2010)
DeRiso et al. (1996)
Fourrier et al. (2000)
353 Patients in an intensive care unit in the USA undergoing coronary artery bypass grafting, valve, or other open-heart surgical procedures. 60 Patients in an intensive care unit in France with a 5-day stay recommendation, requiring mechanical ventilation.
Houston et al. (2002)
561 Patients in an intensive care unit in the USA, requiring intubation.
Panchabhai et al. (2009)
512 Patients in an intensive care unit in India, 171 of which required mechanical ventilation.
Segers et al. (2006)
991 Patients in an intensive care unit in the Netherlands, following cardiac surgery.
N = 270 70% male Intervention: 0.12% chlorhexidine rinse twice daily postoperatively for 10 days or until extubation N = 224 Mean age: 35.2 15.9 61% male Intervention: Oral and pharyngeal suction followed by 0.2% chlorhexidine oral swab, twice daily N = 485 Mean age: 65.3 10.4 74% male Intervention: 0.12% chlorhexidine rinse/nasal ointment, 4 times/day
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Treatment
High Not reported The treatment group group had significantly less case counts of fevers and deaths due to aspiration pneumonia Adachi et al. (2002) Toothbrushing
141 Patients requiring daily care in two nursing homes in Japan.
N = 40 Intervention: Scaling and brushing with an electric brush, an interdental brush, and a sponge brush, once weekly
High Not reported No significant differences in the incidence of pneumonia between the two groups
N=3 Mean age: 73.7 (62–81) 67% male Intervention: suctioning soft foam swab and half strength hydrogen peroxide, 6 times/day N = 48 Intervention: basic oral hygiene consisting of mainly swabbing with a sponge brush and denture cleaning Bopp et al. (2006) Chlorhexidine + toothbrushing
5 Patients in a critical care unit in the USA, requiring intubation.
N=2 Mean age: 40 (28–52) 0% male Intervention: 0.12% chlorhexidine plus tooth brushing 2 times/day
Overall risk of bias? Potential conflicts of interest? Outcome Author, date Treatment
Table 2 (Continued )
Population
Intervention
Control treatment
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457
miscellaneous biases. No attempts were made to contact authors to inquire on methodological issues that were not clearly reported. Despite the heterogeneity between studies regarding their interventions and settings, the general trend amongst the included studies suggested a correlation between good oral care and lower rates of hospitalacquired pneumonia (Tables 2 and 3). Of the studies examining the effects of chlorhexidine rinse or gel, only 7 of the studies were able to demonstrate a positive significant effect in lowering the risk of hospital-acquired/ ventilator-associated pneumonia in patients. In the 13 studies that did not suggest a significant effect of chlorhexidine, the effects have been hypothesized to be masked by the fact that tooth brushing presented as a potential confounder in a number of the studies (Berry et al., 2011), or that not enough statistical power was available (Fourrier et al., 2005). The effects of tooth brushing on pneumonia rates, reviewed by six studies, was only demonstrated to be effective in one of the studies, while it was suggested in the other five studies to only have a significant effect on plaque level reduction. The effects of professional oral health cleaning, antibiotic solution, povidine iodine swab, and sodium bicarbonate rinse on pneumonia rates were studied by 1–2 studies each, with only the first three interventions found to be significantly effective in lowering pneumonia rates. 4. Discussion The purpose of this systematic review was to find evidence to demonstrate reversibility between oral health and pneumonia, and to identify effective prophylactic oral health procedures for the prevention of hospital-acquired and ventilator-associated pneumonia. Given the large amount of heterogeneity between the included studies, we felt it inappropriate to amalgamate the results of the included studies, which in turn limited our ability to draw sound conclusions. Nevertheless, through a review of the overall trend presented within current evidence it can be deduced that, as was reported by Azarpazhooh and Leake (2006), the use of oropharyngeal decontamination using various antimicrobial interventions will likely result in a risk reduction in the progression and occurrence of respiratory diseases, specifically pertaining to hospitalacquired respiratory infections among high-risk populations. By reviewing the evidence we have presented a number of interventions proposed as being effective means of reducing the risk of acquiring pneumonia in an intensive care unit or nursing home setting. Though a number of studies implied that there might be a significant effect with the use of chlorhexidine in its ability to reduce the risk of acquiring hospital-acquired and ventilator-associated pneumonia, it is nevertheless important to note that twelve of the seventeen studies reviewing the efficacy of chlorhexidine failed to demonstrate a significant effect. A few points of consideration come to mind when evaluating these studies: firstly, it should be noted that 7 of the 13 studies that failed to show a significant effect possessed
458
Table 3 A summary of the characteristics and results of the included studies evaluating the rates of ventilator-associated pneumonia. Author, date
Population
Intervention
Control treatment
Outcome
Potential conflicts of Interest?
Overall risk of bias?
Antibiotic Rinse
Pugin et al. (1991)
52 Patients in an intensive care unit in Switzerland, dependent on a ventilator.
N = 27 Mean age: 46 20 74% male Intervention: topical application of placebo solution.
Incidence of ventilator-associated pneumonia was significantly less in the treatment group than the control group.
Not reported
High
Chlorhexidine
BellissimoRodrigues et al. (2009)
198 Patients in an intensive care unit in Brazil with an expected duration of >48 h. Only 133 patients were on mechanical ventilation. 109 Patients in an intensive care unit in Australia with an expected duration of >48 h on mechanical ventilation.
N = 25 Mean age: 45 20 76% male Intervention: topical application of a solution of polymixin B sulfate, neomycin sulfate, and vancomycin (PNV). N = 98 (64 on ventilation) Mean age: 62.5 (17–89) 47% male Intervention: 0.12% chlorhexidine and brushing 3 times/day.
N = 96 (69 on ventilation) Mean age: 54 (15–85) 51% male Intervention: brushing and placebo rinse 3 times/day.
Rates of respiratory infections and ventilator-associated pneumonia were similar between the two groups.
No
Medium
N = 43 Mean age: 59 18 56% male Intervention: sterile water rinse every 2 h, plus cleaning with toothbrush and toothpaste three times/day.
No significant differences in rates of ventilator-associated pneumonia were found between the three groups.
No
High
N = 114 Mean age: 61.1 14.9 64% male Intervention: decontamination of gingival and dental plaque with a placebo gel three times a day.
No significant differences in nosocomial infection rates were found between the two test groups.
No
Medium
N = 24 46% male Intervention: Usual oral comfort care (details not provided).
No significant differences in the rates of ventilator-associated pneumonia between the two groups.
Not reported
High
N = 73 Mean age: 10.8 months (0–204) 48% male Intervention: Oral care with placebo solution.
No significant differences in the rates of ventilator-associated pneumonia between the two groups.
No
Low
Berry et al. (2011)
Fourrier et al. (2005)
Grap et al. (2011)
Jacomo et al. (2011)
228 Patients in six intensive care units in France requiring endotracheal intubation and mechanical ventilation. Anticipated length of stay was >5 days. 152 Patients in an intensive care unit in the USA requiring endotracheal intubation.
164 Patients in a pediatric intensive care unit in Brazil, some of which required ventilators.
Group A: N = 33 Mean age: 60 18 55% male Intervention: sodium bicarbonate mouthwash every 2 h, plus cleaning with toothbrush and toothpaste three times/day. Group B: N = 33 Mean age: 58 19 51% male Intervention: same as Group B plus 0.2% chlorhexidine gel twice daily. N = 114 Mean age: 61.0 14.7 72.8% male Intervention: antiseptic decontamination of gingival and dental plaque with 0.2% chlorhexidine gel three times a day. N = 36 75% male Intervention: 0.12% chlorhexidine applied by swab at least 12 h prior to intubation, plus usual oral comfort care (details not provided). N = 87 Mean age: 12.2 months (0–176) 48% male Intervention: Oral care with 0.12% chlorhexidine solution.
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Treatment
Koeman et al. (2006)
Meinberg et al. (2012)
¨ zc¸aka et al. O (2012)
96 Patients in a pediatric intensive care unit in Brazil, likely to require ventilation within 24 h of admission. 52 Patients in an intensive care unit in Brazil, requiring ventilation for >72 h. 66 Patients in an intensive care unit in Turkey, expecting to require ventilation for >48 h.
Scannapieco et al. (2009)
175 Patients in an intensive care unit in the USA, expected to be intubated and mechanically ventilated within 48 h of admission.
Sebastian et al. (2012)
86 Patients in a pediatric intensive care unit in India, requiring intubation and mechanical ventilation. 207 Patients in an intensive care unit in Thailand, requiring mechanical ventilation.
Tantipong et al. (2008)
Group A: N = 127 Mean age: 60.9 15.3 56% male Intervention: Oral decontamination with 2% chlorhexidine in Vaseline petroleum jelly four times/day. Group B: N = 128 Mean age: 62.4 19.1 52% male Intervention: Oral decontamination with 2% chlorhexidine and 2% colistin in Vaseline petroleum jelly four times/ day. N = 46 Mean age: 12 50 months 61% male Intervention: Tooth brushing and 0.12% chlorhexidine gel twice daily. N = 28 Mean age: 40.1 14.6 Intervention: 2% chlorhexidine gel plus toothbrushing four times/day N = 32 Mean age: 60.5 14.7 Intervention: 0.2% chlorhexidine oral swab, four times/day. Group A: N = 47 Mean age: 44.8 19.9 74% male Intervention: 0.12% chlorhexidine applied once daily and placebo once daily applied to the oral cavity, and brushing twice daily. Group B: N = 50 Mean age: 47.6 19.1 76% male Intervention: 0.12% chlorhexidine applied twice daily to the oral cavity, along with brushing twice daily. N = 41 Mean age: 3 months to 15 years 56% male Intervention: Suction followed by 1% chlorhexidine gel three times/day. N = 102 Mean age: 56.5 20.1 % male Intervention: 2% chlorhexidine oral rub, tooth brushing, and suctioning of oral secretions, four times/day
N = 130 Mean age: 62.1 15.9 72% male Intervention: Oral decontamination with Vaseline petroleum jelly 4 times/day.
Significantly lower incidence of ventilator-associated pneumonia reported in the treatment groups.
No
Medium
N = 50 Mean age: 34.5 60 months 64% male Intervention: Tooth brushing and placebo gel twice daily. N = 24 Mean age: 41.0 19.0 Intervention: placebo gel plus toothbrushing four times/day N = 34 Mean age: 56 18.2 Intervention: Placebo oral swab, four times/day.
No significant differences in the incidence of ventilator-associated pneumonia were found.
No
Low
No significant differences in the incidence of ventilator-associated pneumonia were found.
No
High
The intervention group had a significantly lower incidence of ventilator-associated pneumonia when compared to the control group. No significant differences in incidence of pneumonia were found between the two groups.
No
Medium
No
Low
No significant differences in incidence of ventilator-associated pneumonia were found between the two groups.
No
Medium
No significant differences in incidence of ventilator-associated pneumonia were found between the two groups.
No
High
N = 49 Mean age: 50 22.5 61% male Intervention: placebo and brushing twice daily.
N = 45 Mean age: 3 months to 15 years 60% male Intervention: Suction followed by placebo gel three times/day. N = 105 Mean age: 60.3 19.1 % male Intervention: Placebo oral rub, tooth brushing, and suctioning of oral secretions, four times/day
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Kusahara et al. (2012)
385 Patients in 5 intensive care units in the Netherlands, requiring mechanical ventilation for >48 h.
459
460
Table 3 (Continued ) Author, date
Population
Intervention
Control treatment
Outcome
Potential conflicts of Interest?
Overall risk of bias?
Iodine
Seguin et al. (2006)
110 Patients in an intensive care unit in France, expected to require mechanical ventilation for >2 days.
N = 31 Mean age: 41 18 64% male Intervention: aspiration of oral secretions every 4 h.
There was a significantly lower incidence of ventilator-associated pneumonia in the iodine treatment group when compared to the other two groups.
No
Medium
Yoneyama et al. (2002)
366 Patients from 11 nursing homes in Japan, followed for two years.
N = 182 Mean age: 82.1 7.5 21% male Intervention: no oral care. some patients performed tooth brushing by themselves once a day or irregularly, but none of them requested oral care from caregivers.
Patients receiving oral care had significantly fewer febrile days, lower pneumonia rates, and fewer deaths due to pneumonia than the control group.
No
High
Lorente et al. (2012)
436 Patients in an intensive care unit in Spain, requiring ventilation for >24 h.
No
Medium
147 Patients intubated for >48 h at an intensive care unit in Spain.
N = 219 Mean age: 60.4 16.6 66% male Intervention: 0.12% chlorhexidine gel only, three times/day. N = 73 Mean age: 52.6 17.2 63% male Intervention: 0.12% chlorhexidine rinse every 8 h.
No significant differences in the incidence of ventilator-associated pneumonia were found.
Pobo et al. (2009)
No significant differences in incidence of ventilator-associated pneumonia were found between the two groups.
No
Low
Prendergast et al. (2012)
78 Patients in an intensive care unit in the USA, intubated within 24 h of admission.
N = 40 Mean age: 51 18.4 58% male Intervention: Standard oral care using manual toothbrush and fluoridated toothpaste, twice daily.
No significant differences in incidence of ventilator-associated pneumonia were found between the two groups.
Not reported
High
Yao et al. (2011)
53 Patients in an intensive care unit in Taiwan, under ventilator support for >48 h.
Group A: N = 36 Mean age: 38 17 74% male Intervention: 10% povidone iodine rinse and aspiration of oral secretions every 4 h Group B: N = 31 Mean age: 38 16 67% male Intervention: saline rinse and aspiration of oral secretions every 4 h. N = 184 Mean age: 82.0 7.8 20% male Intervention: caregivers cleaned patients’ teeth with a toothbrush for 5 minutes or swabbed with povidine iodine (1%) after each meal, plus weekly professional care such as plaque and calculus control as necessary. N = 217 Mean age: 61 15.6 67% male Intervention: 0.12% chlorhexidine gel and toothbrushing, three times/day. N = 74 Mean age: 55.3 17.9 66% male Intervention: electric tooth brushing plus 0.12% chlorhexidine rinse every 8 h. N = 38 Mean age: 54 17.8 50% male Intervention: Tongue scraping and tooth brushing with electric toothbrush with non-foaming toothpaste, twice daily. N = 28 Mean age: 60.7 16.0 61% male Intervention: twice daily tooth brushing with purified water, plus daily oral care using cotton swabs.
N = 25 Mean age: 60.5 16.5 68% male Intervention: daily oral care using cotton swabs.
After 7 days of tooth brushing, the experimental group had significantly lower ventilatorassociated pneumonia rates and better oral health and plaque indices.
No
Medium
Toothbrushing
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Treatment
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461
Fig. 2. Forest plots summarizing the results of the included studies. Due to the clinical heterogeneity between included studies, data synthesis was precluded.
potential confounding factors, with all 7 studies (including the only three low risk studies evaluating chlorhexidine) providing their control groups with frequent brushing regimens. Secondly, as suggested earlier, given the relatively low sample sizes of the majority of the studies reviewed in this paper, it is likely that many of the studies that failed to demonstrate a significant effect of chlorhexidine on reducing hospital-acquired and ventilator-associated pneumonia risks possessed inadequate power to detect significant differences between the treatment and
control groups, particularly in the study by Bopp et al. (2006), which only possessed a sample size of 5. Thirdly, it should be noted that all but three of the studies reviewing the efficacy of chlorhexidine were rated as having a medium to high risk of bias. Therefore, while it is suggested that chlorhexidine may have a significant effect on reducing the incidence of ventilator-associated and hospital-acquired pneumonia in high-risk populations, caution should be taken when making definitive conclusions regarding its efficacy.
462
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Fig. 3. A breakdown of the risks of bias of the included studies.
Evidence of the efficacy of tooth brushing to reduce the likelihood of acquiring hospital-acquired or ventilatorassociated pneumonia, when compared to that presented by the studies evaluating chlorhexidine, has not been as well established, with numerous studies suggesting that the short-term effects in reducing risks in intensive care unit patients are negligible. Nevertheless, as expected, tooth brushing was shown in a number of the studies to have a significant effect in reducing plaque levels in patients, and has been suggested to have positive longterm effects in reducing pneumonia risks in individuals in a
nursing home setting. Comparatively, the use of antibiotic rinses or povidine iodine, though proposed to be effective means of reducing hospital-acquired and ventilatorassociated pneumonia infection risks, have only been studied in studies with medium to high risks of bias, and therefore warrant subsequent study before sound conclusions of their efficacies can be made. It should be noted that though all included trials within this report were of a randomized controlled design, the risk of bias evaluation revealed that the majority of the included studies presented with a moderate to high risk of bias. Thus, caution should be taken when translating the recommendations of this study to clinical practice. Efforts should be made to increase the number of low-risk RCTs evaluating the effectiveness of the less established oral health procedures, and updating the recommendations presented in this review as new evidence is made available. Given the intimate role that nurses of all types play in patient health care in intensive care units and nursing homes, nurses present a unique opportunity to help reduce the risks of hospital-acquired or ventilator-associated pneumonia by implementing oral health care practices into routine patient care. As it is intrinsic that the most effective means to ensure the minimization of death tolls and health care costs due to hospital-acquired and ventilator-associated pneumonia is through prevention, it is therefore recommended that nurses integrate the latest evidence-based oral health care procedures into routine patient care protocols, focusing on patients at high risk for acquiring pneumonia. Based on the results of the current review, it is recommended that chlorhexidine rinse or swab be used as a frequent means of oral prophylaxis, given that its efficacy has been reasonably insinuated in the current literature. If the use of chlorhexidine is contraindicated, other means to disinfect the oral cavity, such as tooth brushing, antibiotic rinse, or povidine iodine swab should be used, as is indicated by the best available evidence. It has been suggested that though nurses understand the importance of oral health and hygiene, efforts to translate this knowledge into practice have yet to take full effect. In a recent review of the literature for nursing education, the authors cite the lack of adequate education and guidelines for nurses to be the main cause for the less than optimal oral care practice today (DeKeyser et al., 2009). Further supporting the need for and importance of oral health education for nurses, a study conducted by Tolentino-DelosReyes et al. (2007) was able to demonstrate, as is expected, that nursing education sessions had a significant positive impact on oral hygiene interventions in clinical practice. Given the importance of oral hygiene in helping to prevent ventilator-associated pneumonia among high risk patients established within this and other studies, it is therefore warranted for efforts to be made in expanding the scope of nursing education to stress the importance of applying adequate, evidence-based oral health care in clinical practice, with an emphasis on highrisk patients. Furthermore, efforts to integrate evidencebased oral health recommendations for preventing hospital-acquired and ventilator-associated pneumonia into routine patient care protocol for high-risk patients of
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intensive care units and long-term care facilities, such as those endorsed by this review are recommended. 5. Conclusion Oral health care is presented as a viable method of reducing the risk of acquiring hospital-acquired or ventilator-associated pneumonia in both intensive care unit and long-term care facilities. Though some studies fail to present it’s effectiveness, the efficacy of chlorhexidine rinses, gels, and swabs as a means of disinfecting the oral cavity has been demonstrated in a number of RCTs. Conversely, evidence supporting the effectiveness of other oral care means still remains scarce and methodologically weak. As such, the next requirement is for large, highquality studies to evaluate the effectiveness of the various oral health interventions in helping to reduce the rates of aspiration pneumonia within the vulnerable groups in health care settings, and to support nursing educational efforts to promote the dissemination of this knowledge into clinical practice. Competing interests The authors declare that they have no competing interests. Funding No sources of funding were sought out for the purposes of this review. Ethical approvalNone declared. References Adachi, M., Ishihara, K., Abe, S., Okuda, K., Ishikawa, T., 2002. Effect of professional oral health care on the elderly living in nursing homes. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 94, 191–195. Amin, A.N., Feinbloom, D., Krekun, S., Li, J., Pak, M., et al., 2004. Recommendations for management of community- and hospital-acquired pneumonia—the hospitalist perspective. Curr. Opin. Pulm. Med. 10, S23–S27. Azarpazhooh, A., Leake, J.L., 2006. Systematic review of the association between respiratory diseases and oral health. J. Periodontol. 77, 1465–1482. Bellissimo-Rodrigues, F., Bellissimo-Rodrigues, W.T., Viana, J.M., Gil Cezar Alkmim Teixeira, M.D., Nicolini, E., et al., 2009. Effectiveness of oral rinse with chlorhexidine in preventing nosocomial respiratory tract infections among intensive care unit patients. Infect. Control Hosp. Epidemiol. 30 (10), 952–958. Berry, A.M., Davidson, P.M., Masters, J., Rolls, K., Ollerton, R., 2011. Effects of three approaches to standardized oral hygiene to reduce bacterial colonization and ventilator associated pneumonia in mechanically ventilated patients: a randomized control trial. Int. J. Nurs. Stud. 48, 681–688. Bopp, M., Darby, M., Loftin, K.C., Broscious, S., 2006. Effects of daily oral care with 0.12% chlorhexidine gluconate and a standard oral care protocol on the development of nosocomial pneumonia in intubated patients: a pilot study. J. Dent. Hyg. 80 (3), 9. C´abov, T., Macan, D., Husedzˇinovic´, I., Sˇkrlin-Sˇubic´, J., Bosˇnjak, D., et al., 2010. The impact of oral health and 0.2% chlorhexidine oral gel on the prevalence of nosocomial infections in surgical intensive-care patients: a randomized placebo-controlled study. Wien. Klin. Wochenschr. 122 (13–14), 397–404. Caruso, P., Denari, S., Ruiz, S.A., Demarzo, S.E., Deheinzelin, D., 2009. Saline instillation before tracheal suctioning decreases the incidence of ventilator-associated pneumonia. Crit. Care Med. 37 (1), 32–38. Centers for Disease Control and Prevention, 2014. Pneumonia http:// www.cdc.gov/pneumonia/ (accessed 7/2/2014).
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