Association Between Daily Toothbrushing and Hospital-Acquired Pneumonia

Importance: Hospital-acquired pneumonia (HAP) is the most common and morbid health care-associated infection, but limited data on effective prevention strategies are available. Objective: To determine whether daily toothbrushing is associated with lower rates of HAP and other patient-relevant outcomes. Data Sources: A search of PubMed, Embase, Cumulative Index to Nursing and Allied Health, Cochrane Central Register of Controlled Trials, Web of Science, Scopus, and 3 trial registries was performed from inception through March 9, 2023. Study Selection: Randomized clinical trials of hospitalized adults comparing daily oral care with toothbrushing vs regimens without toothbrushing. Data Extraction and Synthesis: Data extraction and risk of bias assessments were performed in duplicate. Meta-analysis was performed using random-effects models. Main Outcomes and Measures: The primary outcome of this systematic review and meta-analysis was HAP. Secondary outcomes included hospital and intensive care unit (ICU) mortality, duration of mechanical ventilation, ICU and hospital lengths of stay, and use of antibiotics. Subgroups included patients who received invasive mechanical ventilation vs those who did not, toothbrushing twice daily vs more frequently, toothbrushing provided by dental professionals vs general nursing staff, electric vs manual toothbrushing, and studies at low vs high risk of bias. Results: A total of 15 trials met inclusion criteria, including 10 742 patients (2033 in the ICU and 8709 in non-ICU departments; effective population size was 2786 after shrinking the population to account for 1 cluster randomized trial in non-ICU patients). Toothbrushing was associated with significantly lower risk for HAP (risk ratio RR, 0.67 95% CI, 0.56-0.81) and ICU mortality (RR, 0.81 95% CI, 0.69-0.95). Reduction in pneumonia incidence was significant for patients receiving invasive mechanical ventilation (RR, 0.68 95% CI, 0.57-0.82) but not for patients who were not receiving invasive mechanical ventilation (RR, 0.32 [95% CI, 0.05-2.02). Toothbrushing for patients in the ICU was associated with fewer days of mechanical ventilation (mean difference, -1.24 95% CI, -2.42 to -0.06 days) and a shorter ICU length of stay (mean difference, -1.78 95% CI, -2.85 to -0.70 days). Brushing twice a day vs more frequent intervals was associated with similar effect estimates. Results were consistent in a sensitivity analysis restricted to 7 studies at low risk of bias (1367 patients). Non-ICU hospital length of stay and use of antibiotics were not associated with toothbrushing. Conclusions: The findings of this systematic review and meta-analysis suggest that daily toothbrushing may be associated with significantly lower rates of HAP, particularly in patients receiving mechanical ventilation, lower rates of ICU mortality, shorter duration of mechanical ventilation, and shorter ICU length of stay. Policies and programs encouraging more widespread and consistent toothbrushing are warranted.