Combination of toothbrushing and chlorhexidine compared with exclusive use of chlorhexidine to reduce the risk of ventilator-associated pneumonia: A systematic review with meta-analysis

Abstract

This study aimed to compare the effectiveness of 0.12% chlorhexidine alone and 0.12% chlorhexidine in combination with toothbrushing to prevent ventilator-associated pneumonia (VAP) in mechanically ventilated patients. The Embase, Latin American and Caribbean Health Science Literature, PubMed, Scientific Electronic Library Online, Scopus, LIVIVO, Web of Science, Cochrane Library, OpenThesis, and Open Access Thesis and Dissertations databases were used. Only randomized controlled trials without restrictions on the year or language of publication were included. Two reviewers assessed the risk of bias using the Joanna Briggs Institute Critical Appraisal Tool. A meta-analysis using a random-effects model estimated the combined relative risk (RR). The Grading of Recommendations, Assessment, Development and Evaluations approach was used to assess the certainty of the evidence. Initially, 2,337 studies were identified, of which 4 were considered in the systematic review and 3 in the meta-analysis (total sample: 796 patients). The studies were published between 2009 and 2017. All eligible studies had a low risk of bias. The meta-analysis revealed that the risk of VAP was 24% lower in patients receiving chlorhexidine combined with toothbrushing than in those receiving chlorhexidine alone (RR: 0.76; 95% confidence interval: 0.55-1.06), with moderate certainty of evidence and without statistical significance. In conclusion, considering the limitations of this study, a standard protocol for the prevention of VAP is not yet recommended. More studies with larger sample sizes are needed to draw strong conclusions. However, considering that toothbrushing is a simple intervention, it should be a common practice in mechanically ventilated patients, especially among patients with coronavirus disease.

Oral Care in Intensive Care Unit and Chlorhexidine: An Endless Story

“…6 Another concern might be the authors' choice to perform oral care without toothbrushing; indeed, they applied a protocol with the teeth cleaning only with foam swabs for ICU patients. 3 In fact, even if a recent systematic review failed to show a significant correlation in the reduction of VAP rates using the combination of 0.12% CHX and toothbrush against the only 0.12% CHX oral rinse, 7 the mechanical action of toothbrushing (in particular, with a powered toothbrush) is a valid mean to reduce the development of biofilm on the teeth surfaces. 8 Zarinfar et al 4 performed a 3-arm randomized controlled trial (RCT) including a ventilator bundle for all the enrolled ICU patients, whereas in 1 arm, they added oral care with CHX mouthwashes twice daily.…”

Association Between Toothbrushing Habits and COVID-19 Symptoms

“…While the reverse causation could explain the association between the increase in the time and the frequency of tooth brushing and having the three main COVID-19 symptoms (supplementary table 1). To explain these pathways in details, it is possible that those who decreased the time and the frequency of tooth brushing could not have benefited from the mechanical cleansing effect of tooth brushing and the protective antiviral effect of the chemicals in the tooth paste, and had higher SARS-CoV-2 viral load intraorally and eventually had higher chances of having the three COVID-19 symptoms 6 , 7 , 8 , 9 , 10 . ( Figure 2 ) illustrates this hypothesized microbial pathway.…”

“…In addition, the previous research examining the association between toothbrushing with similar respiratory diseases such as pneumonia, showed that tooth brushing was associated with lower ໿incidence, duration, and mortality of pneumonia in community dwelling individuals and hospitalized patients 7 , 8 . A systematic review with meta-analysis concluded that the risk of ventilator-associated pneumonia (VAP) was 24% lower in patients receiving chlorhexidine mouthwash combined with toothbrushing than in those receiving chlorhexidine mouthwash only 9 . Also, some growing evidence from the industry of oral care products suggested that certain toothpastes containing zinc, stannous fluoride, or amine fluoride may play a role in temporarily reducing the viral load of the SARS-CoV-2 intraorally 10 .…”

Prevention and treatment of ventilator-associated pneumonia in COVID-19

“…Chlorhexidine, a drug used in oral hygiene care for over 2 decades, can reduce oral colonization, and prevent the occurrence of VAP ( Zand et al, 2017 ). Besides, the combination of chlorhexidine with toothbrushing was more satisfactory in preventing VAP in patients on mechanical ventilation, compared with chlorhexidine alone ( Silva et al, 2021 ). However, several studies were questioning the efficacy and safety of oral chlorhexidine.…”