Background
Ventilator-associated pneumonia (VAP) is defined as pneumonia developing in people who have received mechanical ventilation for at least 48 hours. VAP is a potentially serious complication in these patients who are already critically ill. Oral hygiene care (OHC), using either a mouthrinse, gel, toothbrush, or combination, together with aspiration of secretions, may reduce the risk of VAP in these patients.

Objectives
To assess the effects of oral hygiene care on incidence of ventilator-associated pneumonia in critically ill patients receiving mechanical ventilation in hospital intensive care units (ICUs).

Search methods
We searched the following electronic databases: Cochrane Oral Health’s Trials Register (to 17 December 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2015, Issue 11), MEDLINE Ovid (1946 to 17 December 2015), Embase Ovid (1980 to 17 December 2015), LILACS BIREME Virtual Health Library (1982 to 17 December 2015), CINAHL EBSCO (1937 to 17 December 2016), Chinese Biomedical Literature Database (1978 to 14 January 2013), China National Knowledge Infrastructure (1994 to 14 January 2013), Wan Fang Database (January 1984 to 14 January 2013) and VIP Database (January 2012 to 4 May 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials to 17 December 2015. We placed no restrictions on the language or date of publication when searching the electronic databases.

Selection criteria
We included randomised controlled trials (RCTs) evaluating the effects of OHC (mouthrinse, swab, toothbrush or combination) in critically ill patients receiving mechanical ventilation for at least 48 hours.

Data collection and analysis
At least two review authors independently assessed search results, extracted data and assessed risk of bias in included studies. We contacted study authors for additional information. We pooled data from trials with similar interventions and outcomes. We reported risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes, using random-effects models unless there were fewer than four studies.

Main results
We included 38 RCTs (6016 participants). There were four main comparisons: chlorhexidine (CHX) mouthrinse or gel versus placebo/usual care; toothbrushing versus no toothbrushing; powered versus manual toothbrushing; and comparisons of oral care solutions. We assessed the overall risk of bias as low in five trials (13%), high in 26 trials (68%), and unclear in seven trials (18%). We did not consider the risk of bias to be serious when assessing the quality of evidence (GRADE) for VAP incidence, but we downgraded other outcomes for risk of bias.

High quality evidence from 18 RCTs (2451 participants, 86% adults) shows that CHX mouthrinse or gel, as part of OHC, reduces the risk of VAP compared to placebo or usual care from 24% to about 18% (RR 0.75, 95% confidence intervals (CI) 0.62 to 0.91, P = 0.004, I2 = 35%). This is equivalent to a number needed to treat for an additional beneficial outcome (NNTB) of 17 (95% CI 9 to 50), which indicates that for every 17 ventilated patients in intensive care receiving OHC including chlorhexidine, one outcome of VAP would be prevented. There is no evidence of a difference between CHX and placebo/usual care for the outcomes of mortality (RR 1.09, 95% CI 0.96 to 1.23, P = 0.20, I2 = 0%, 14 RCTs, 2014 participants, moderate quality evidence), duration of mechanical ventilation (MD -0.09 days, 95% CI -1.73 to 1.55 days, P = 0.91, I2 = 36%, five RCTs, 800 participants, low quality evidence), or duration of intensive care unit (ICU) stay (MD 0.21 days, 95% CI -1.48 to 1.89 days, P = 0.81, I2 = 9%, six RCTs, 833 participants, moderate quality evidence). There is insufficient evidence to determine the effect of CHX on duration of systemic antibiotics, oral health indices, caregivers' preferences or cost. Only two studies reported any adverse effects, and these were mild with similar frequency in CHX and control groups.

We are uncertain as to the effects of toothbrushing (± antiseptics) on the outcomes of VAP (RR 0.69, 95% CI 0.44 to 1.09, P = 0.11, I2 = 64%, five RCTs, 889 participants, very low quality evidence) and mortality (RR 0.87, 95% CI 0.70 to 1.09, P = 0.24, I2 = 0%, five RCTs, 889 participants, low quality evidence) compared to OHC without toothbrushing (± antiseptics). There is insufficient evidence to determine whether toothbrushing affects duration of mechanical ventilation, duration of ICU stay, use of systemic antibiotics, oral health indices, adverse effects, caregivers' preferences or cost.

Only one trial (78 participants) compared use of a powered toothbrush with a manual toothbrush, providing insufficient evidence to determine the effect on any of the outcomes of this review.

Fifteen trials compared various other oral care solutions. There is very weak evidence that povidone iodine mouthrinse is more effective than saline/placebo (RR 0.69, 95% CI 0.50 to 0.95, P = 0.02, I2 = 74%, three studies, 356 participants, high risk of bias), and that saline rinse is more effective than saline swab (RR 0.47, 95% CI 0.37 to 0.62, P < 0.001, I2 = 84%, four studies, 488 participants, high risk of bias) in reducing VAP. Due to variation in comparisons and outcomes among trials, there is insufficient evidence concerning the effects of other oral care solutions.

Authors' conclusions
OHC including chlorhexidine mouthwash or gel reduces the risk of developing ventilator-associated pneumonia in critically ill patients from 24% to about 18%. However, there is no evidence of a difference in the outcomes of mortality, duration of mechanical ventilation or duration of ICU stay. There is no evidence that OHC including both antiseptics and toothbrushing is different from OHC with antiseptics alone, and some weak evidence to suggest that povidone iodine mouthrinse is more effective than saline/placebo, and saline rinse is more effective than saline swab in reducing VAP. There is insufficient evidence to determine whether powered toothbrushing or other oral care solutions are effective in reducing VAP. There is also insufficient evidence to determine whether any of the interventions evaluated in the studies are associated with adverse effects.

/pdf/oral-hygiene-care-for-critically-ill-patients-to-prevent-2dpl6haixo.pdf

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

RESULTS There were fewer lower respiratory tract infections in cardiac surgery patients randomized to chlorhexidine (relative risk [RR], 0.56 [95% CI, 0.41-0.77]) but no significant difference in ventilator-associated pneumonia risk in double-blind studies of non–cardiac surgery patients (RR, 0.88 [95% CI, 0.66-1.16]). There was no significant mortality difference between chlorhexidine and placebo in cardiac surgery studies (RR, 0.88 [95% CI, 0.25-2.14]) and nonsignificantly increased mortality in non–cardiac surgery studies (RR, 1.13 [95% CI, 0.99-1.29]). There were no significant differences in mean duration of mechanical ventilation or intensive care length of stay. Data on hospital length of stay and antibiotic prescribing were limited.

/pdf/reappraisal-of-routine-oral-care-with-chlorhexidine-bi63y0fxq7.pdf

Reappraisal of routine oral care with chlorhexidine gluconate for patients receiving mechanical ventilation: systematic review and meta-analysis.

BACKGROUND\nVentilator-associated pneumonia (VAP) is defined as pneumonia developing in people who have received mechanical ventilation for at least 48 hours. VAP is a potentially serious complication in these patients who are already critically ill. Oral hygiene care (OHC), using either a mouthrinse, gel, toothbrush, or combination, together with aspiration of secretions, may reduce the risk of VAP in these patients.\n\n\nOBJECTIVES\nTo assess the effects of oral hygiene care on incidence of ventilator-associated pneumonia in critically ill patients receiving mechanical ventilation in hospital intensive care units (ICUs).\n\n\nSEARCH METHODS\nWe searched the following electronic databases: Cochrane Oral Health's Trials Register (to 17 December 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2015, Issue 11), MEDLINE Ovid (1946 to 17 December 2015), Embase Ovid (1980 to 17 December 2015), LILACS BIREME Virtual Health Library (1982 to 17 December 2015), CINAHL EBSCO (1937 to 17 December 2016), Chinese Biomedical Literature Database (1978 to 14 January 2013), China National Knowledge Infrastructure (1994 to 14 January 2013), Wan Fang Database (January 1984 to 14 January 2013) and VIP Database (January 2012 to 4 May 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials to 17 December 2015. We placed no restrictions on the language or date of publication when searching the electronic databases.\n\n\nSELECTION CRITERIA\nWe included randomised controlled trials (RCTs) evaluating the effects of OHC (mouthrinse, swab, toothbrush or combination) in critically ill patients receiving mechanical ventilation for at least 48 hours.\n\n\nDATA COLLECTION AND ANALYSIS\nAt least two review authors independently assessed search results, extracted data and assessed risk of bias in included studies. We contacted study authors for additional information. We pooled data from trials with similar interventions and outcomes. We reported risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes, using random-effects models unless there were fewer than four studies.\n\n\nMAIN RESULTS\nWe included 38 RCTs (6016 participants). There were four main comparisons: chlorhexidine (CHX) mouthrinse or gel versus placebo/usual care; toothbrushing versus no toothbrushing; powered versus manual toothbrushing; and comparisons of oral care solutions. We assessed the overall risk of bias as low in five trials (13%), high in 26 trials (68%), and unclear in seven trials (18%). We did not consider the risk of bias to be serious when assessing the quality of evidence (GRADE) for VAP incidence, but we downgraded other outcomes for risk of bias.High quality evidence from 18 RCTs (2451 participants, 86% adults) shows that CHX mouthrinse or gel, as part of OHC, reduces the risk of VAP compared to placebo or usual care from 25% to about 19% (RR 0.74, 95% confidence intervals (CI) 0.61 to 0.89, P = 0.002, I2 = 31%). This is equivalent to a number needed to treat for an additional beneficial outcome (NNTB) of 17 (95% CI 10 to 33), which indicates that for every 17 ventilated patients in intensive care receiving OHC including chlorhexidine, one outcome of VAP would be prevented. There is no evidence of a difference between CHX and placebo/usual care for the outcomes of mortality (RR 1.09, 95% CI 0.96 to 1.23, P = 0.18, I2 = 0%, 15 RCTs, 2163 participants, moderate quality evidence), duration of mechanical ventilation (MD -0.09 days, 95% CI -1.73 to 1.55 days, P = 0.91, I2 = 36%, five RCTs, 800 participants, low quality evidence), or duration of intensive care unit (ICU) stay (MD 0.21 days, 95% CI -1.48 to 1.89 days, P = 0.81, I2 = 9%, six RCTs, 833 participants, moderate quality evidence). There is insufficient evidence to determine the effect of CHX on duration of systemic antibiotics, oral health indices, caregivers' preferences or cost. Only two studies reported any adverse effects, and these were mild with similar frequency in CHX and control groups.We are uncertain as to the effects of toothbrushing (± antiseptics) on the outcomes of VAP (RR 0.69, 95% CI 0.44 to 1.09, P = 0.11, I2 = 64%, five RCTs, 889 participants, very low quality evidence) and mortality (RR 0.87, 95% CI 0.70 to 1.09, P = 0.24, I2 = 0%, five RCTs, 889 participants, low quality evidence) compared to OHC without toothbrushing (± antiseptics). There is insufficient evidence to determine whether toothbrushing affects duration of mechanical ventilation, duration of ICU stay, use of systemic antibiotics, oral health indices, adverse effects, caregivers' preferences or cost.Only one trial (78 participants) compared use of a powered toothbrush with a manual toothbrush, providing insufficient evidence to determine the effect on any of the outcomes of this review.Fifteen trials compared various other oral care solutions. There is very weak evidence that povidone iodine mouthrinse is more effective than saline/placebo (RR 0.69, 95% CI 0.50 to 0.95, P = 0.02, I2 = 74%, three studies, 356 participants, high risk of bias), and that saline rinse is more effective than saline swab (RR 0.47, 95% CI 0.37 to 0.62, P < 0.001, I2 = 84%, four studies, 488 participants, high risk of bias) in reducing VAP. Due to variation in comparisons and outcomes among trials, there is insufficient evidence concerning the effects of other oral care solutions.\n\n\nAUTHORS' CONCLUSIONS\nOHC including chlorhexidine mouthwash or gel reduces the risk of developing ventilator-associated pneumonia in critically ill patients from 25% to about 19%. However, there is no evidence of a difference in the outcomes of mortality, duration of mechanical ventilation or duration of ICU stay. There is no evidence that OHC including both antiseptics and toothbrushing is different from OHC with antiseptics alone, and some weak evidence to suggest that povidone iodine mouthrinse is more effective than saline/placebo, and saline rinse is more effective than saline swab in reducing VAP. There is insufficient evidence to determine whether powered toothbrushing or other oral care solutions are effective in reducing VAP. There is also insufficient evidence to determine whether any of the interventions evaluated in the studies are associated with adverse effects.

/pdf/oral-hygiene-care-for-critically-ill-patients-to-prevent-279cizto19.pdf

Oral hygiene care for critically ill patients to prevent ventilator associated pneumonia [Intervention Protocol]

Objectives To determine the effect on mortality of selective digestive decontamination, selective oropharyngeal decontamination, and topical oropharyngeal chlorhexidine in adult patients in general intensive care units and to compare these interventions with each other in a network meta-analysis. Design Systematic review, conventional meta-analysis, and network meta-analysis. Medline, Embase, and CENTRAL were searched to December 2012. Previous meta-analyses, conference abstracts, and key journals were also searched. We used pairwise meta-analyses to estimate direct evidence from intervention-control trials and a network meta-analysis within a Bayesian framework to combine direct and indirect evidence. Inclusion criteria Prospective randomised controlled trials that recruited adult patients in general intensive care units and studied selective digestive decontamination, selective oropharyngeal decontamination, or oropharyngeal chlorhexidine compared with standard care or placebo. Results Selective digestive decontamination had a favourable effect on mortality, with a direct evidence odds ratio of 0.73 (95% confidence interval 0.64 to 0.84). The direct evidence odds ratio for selective oropharyngeal decontamination was 0.85 (0.74 to 0.97). Chlorhexidine was associated with increased mortality (odds ratio 1.25, 1.05 to 1.50). When each intervention was compared with the other, both selective digestive decontamination and selective oropharyngeal decontamination were superior to chlorhexidine. The difference between selective digestive decontamination and selective oropharyngeal decontamination was uncertain. Conclusion Selective digestive decontamination has a favourable effect on mortality in adult patients in general intensive care units. In these patients, the effect of selective oropharyngeal decontamination is less certain. Both selective digestive decontamination and selective oropharyngeal decontamination are superior to chlorhexidine, and there is a possibility that chlorhexidine is associated with increased mortality.

https://www.bmj.com/content/bmj/348/bmj.g2197.full.pdf

Selective digestive or oropharyngeal decontamination and topical oropharyngeal chlorhexidine for prevention of death in general intensive care: systematic review and network meta-analysis.

Oral care is a basic nursing care activity that provides relief and comfort to patients who are seriously ill and cannot perform this simple activity themselves. In a critical care unit, providing oral care to patients who are uncooperative, have a high risk for aspiration, or are intubated can be a challenge and, at times, an impossible task. However, if the benefit of oral care outweighs the risk, clear, precise oral care procedures and adequate evidence to support these processes are needed. If providing systematic oral care can decrease the incidence of pneumonia and other outcome measures, the care should be considered an important and critical component of critical care nursing. Except for investigations1–3 in cardiac surgery patients, few studies4,5 have demonstrated these benefits from oral care. Studies of specific oral care practices, such as oral decontamination and toothbrushing, including use of powered toothbrushes, have not resulted in improvements in duration of mechanical ventilation, length of hospital stay, or mortality.6,7 A recent randomized clinical trial8 in critical care patients receiving mechanical ventilation indicated that powered toothbrushes reduced plaque burden, but other outcome measures, such as ventilator-associated pneumonia (VAP), were not included in the trial.

In addition to the lack of outcome data to support oral care, no standard oral assessment tools for determining the frequency and procedure for oral care are available. Treloar and Stechmiller9 developed an oral assessment tool and tested it on 16 intubated patients. However, no information on psychometric testing was provided, and the oral assessment lacked quantitative metrics or scales. Fitch et al10 used a 100-mm visual analog scale to assess the different structures in the oral cavity. In this 3-phase, longitudinal study,10 30 patients were treated according to a specific oral care protocol that included brushing with a child's toothbrush. Although the oral care was performed by the nursing staff in less than 5 minutes, no specific information was provided on the time required to perform the oral assessment. The results indicated a significant difference in the mean inflammation score between the oral care group and the comparison group, but no other variable differed between the 2 groups. Finally, Fourrier et al11 used a plaque index score12 and a dental assessment by an odontologist to assess 228 intubated patients in a double-blind, placebo-controlled trial of chlorhexidine gel for prevention of respiratory infections. Although the number of plaque cultures positive for pathogens was decreased in the intervention group by day 10, the rate of VAP, days of mechanical ventilation, and other outcome measures did not differ between the 2 groups. In a recent single-center study, Munro et al13 examined the effect of toothbrushing alone, chlorhexidine alone, and toothbrushing plus chlorhexidine in reducing the rate of VAP. The decayed, missing, and filled teeth index was used as a baseline assessment of general oral health. In a subgroup analysis of patients who did not have elevated pneumonia scores at baseline and received chlorhexidine, pneumonia rates on day 3 were reduced.

No standard oral assessment tools to determine oral care frequency and procedure are available.

Another area of research is health care practitioners' oral care practices, in particular the practices of nurses and respiratory therapists. Although nurses think oral care is important, many use inadequate instruments such as foam sponges to perform oral care.14 In addition, nurses acknowledge that oral care procedures are not evidence based.15–17

Many performance improvement studies of VAP and oral care have been published. Some of the investigators18,19 found significant decreases in VAP rates after instituting numerous interventions including oral care. However, in these studies, oral care frequency and type were not clearly defined or consisted solely of chlorhexidine rinses.18,20 None of the studies included any oral assessment measure to determine the effects of oral care.

Recently, having critical care nurses provide oral care has received increased emphasis. National organizations21,22 have listed oral care in a number of prevention interventions. Providing evidence-based oral care requires data to support the intervention. Reliable and valid measures for oral assessment are essential to measure progress and guide intervention. In our study, we used a modified Beck Oral Assessment Scale (BOAS)23 and the mucosal-plaque score (MPS)24,25 to assess the oral cavity (Table 1 and Figure 1).



Figure 1

Mucosal-Plaque Score (MPS).a





Table 1

Beck Oral Assessment Score (BOAS), modifieda



The purpose of our study was to examine the effects of a systematic oral care program in improving oral assessment scores in critically ill patients in 3 intensive care units.

Effects of Systematic Oral Care in Critically Ill Patients: A Multicenter Study

Background Oropharyngeal colonization with pathogenic organisms contributes to the development of ventilator-associated pneumonia in intensive care units Although considered basic and potentially nonessential nursing care, oral hygiene has been proposed as a key intervention for reducing ventilator-associated pneumonia Nevertheless, evidence from randomized controlled trials that could inform best practice is limited Objective To appraise the peer-reviewed literature to determine the best available evidence for providing oral care to intensive care patients receiving mechanical ventilation and to document a research agenda for this important activity in optimizing patients' outcomes Methods Articles published from 1985 to 2006 in English and indexed in the CINAHL, MEDLINE, Joanna Briggs Institute, Cochrane Library, EMBASE, and DARE databases were searched by using the key terms oral hygiene, oral hygiene practices, oral care, mouth care, mouth hygiene, intubated, mechanically ventilated, intensive care, and critical care Reference lists of retrieved journal articles were searched for publications missed during the primary search Finally, the Google search engine was used to do a comprehensive search of the World Wide Web to ensure completeness of the search The search strategy was verified by a health librarian Results The search yielded 55 articles: 11 prospective controlled trials, 20 observational studies, and 24 descriptive reports Methodological issues and the heterogeneity of samples precluded meta-analysis Conclusions Despite the importance of providing oral hygiene to intensive care patients receiving mechanical ventilation, high-level evidence from rigorous randomized controlled trials or high-quality systematic reviews that could inform clinical practice is scarce

Systematic Literature Review of Oral Hygiene Practices for Intensive Care Patients Receiving Mechanical Ventilation

Effects of three approaches to standardized oral hygiene to reduce bacterial colonization and ventilator associated pneumonia in mechanically ventilated patients: A randomised control trial

Janet Masters

Papers

Systematic Literature Review of Oral Hygiene Practices for Intensive Care Patients Receiving Mechanical Ventilation

Effects of three approaches to standardized oral hygiene to reduce bacterial colonization and ventilator associated pneumonia in mechanically ventilated patients: A randomised control trial

Patients Receiving Mechanical Ventilation Systematic Literature Review of Oral Hygiene Practices for Intensive Care