Review
Prophylactic oral health procedures to prevent hospital-acquired and ventilator-associated pneumonia: A systematic review

https://doi.org/10.1016/j.ijnurstu.2014.07.010Get rights and content

Abstract

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 Scholar™.

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 hospital-acquired 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.

Conclusions

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. 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.

Section snippets

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

Study eligibility criteria

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

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).

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

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

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.

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