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Daily toothbrushing was associated with lower rates of hospital-acquired pneumonia (HAP) and intensive care unit (ICU) mortality, according to results from a systematic review and meta-analysis of randomized trials.

In an effective population size of 2,786 patients, daily toothbrushing was associated with a reduced risk of HAP (risk ratio [RR] 0.67, 95% CI 0.56-0.81) and a reduced risk of ICU mortality (RR 0.81, 95% CI 0.69-0.95), reported Selina Ehrenzeller, MD, and Michael Klompas, MD, MPH, of Harvard Medical School and Brigham and Women's Hospital in Boston, in .

"It's unusual to find a preventative strategy that lowers mortality rates. And to think that it's something as simple and inexpensive as toothbrushing is remarkable," Klompas told MedPage Today in an email.

Moreover, reduction in pneumonia incidence was significant for patients receiving invasive mechanical ventilation (RR 0.68, 95% CI 0.57-0.82), but not for those who were not receiving this treatment (RR 0.32, 95% CI 0.05-2.02). Daily toothbrushing was associated with an average of 1.24 fewer days on mechanical ventilation (95% CI -2.42 to -0.06), and 1.78 fewer days spent in the ICU (95% CI -2.85 to -0.70).

Brushing twice a day compared with more frequently was associated with similar outcomes.

"We hope that doctors will get an enhanced appreciation of the importance of toothbrushing in hospitalized patients. Our study suggests that the benefits of toothbrushing extend beyond simply maintaining or improving oral hygiene," Klompas said.

In an , Rupak Datta, MD, PhD, of the Veterans Affairs Connecticut Healthcare System in West Haven and Yale School of Medicine in New Haven, noted that "the precise components of oral care [to prevent HAP] remain unclear due in large part to conflicting studies with respect to oral chlorhexidine."

Previously, chlorhexidine oral rinses were recommended to prevent ventilator-associated pneumonia, but its use for oral decontamination in the ICU was found to be associated with increased mortality, he explained. "These conflicting studies left the field with a lack of clarity on strategies to prevent HAP."

In the current meta-analysis, the lower rate of HAP was primarily driven by the influence of toothbrushing on ventilator-associated pneumonia rather than on non-ventilator HAP, Datta said.

However, "the effect estimates on combining these 2 studies [on non-ventilator HAP] was consistent with the primary analysis, but the sample size was small, the 95% CI was broad, and the signal was not statistically significant," the study authors wrote. "This suggests that toothbrushing could also prevent non-ventilator HAP but more data are needed to confirm or refute this possibility."

For this systematic review and meta-analysis, Ehrenzeller and Klompas searched PubMed, Embase, Cumulative Index to Nursing and Allied Health, Cochrane Central Register of Controlled Trials, Web of Science, Scopus, and three trial registries from inception through March 9. They included 15 trials involving 10,742 patients (2,033 in the ICU and 8,709 in non-ICU departments), and the effective population size was 2,786 after shrinking the population to account for one cluster randomized trial in non-ICU patients.

The researchers also looked at whether toothbrushing was provided by dental professionals or general nursing staff and if manual toothbrushing versus electric toothbrushing was used; however, meaningful analysis of these parameters was not possible due to the small number of studies that included these data.

"It is unclear what expertise is required to provide oral care in ventilated patients," Datta wrote. "Two studies had toothbrushing performed by dental professionals, whereas nondental nursing staff performed oral care in all others. The technique differed among studies included, suggesting the need for studies that help standardize this practice."

The study had several limitations, the authors noted. Studies were primarily from Asia, South America, and Europe, where HAP prevention strategies are likely to differ from the U.S. In addition, the follow-up periods of included studies were short in some, which may have resulted in failure to detect all cases of pneumonia. Lack of double-blinding may also have influenced outcomes as well.

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