Study: Daily Toothbrushing Associated with Lower Rates of Hospital-Acquired Pneumonia

Daily toothbrushing may be associated with lower rates of hospital-acquired pneumonia (HAP) and intensive care unit mortality, including invasive mechanical ventilation, according to results of a study published in JAMA Internal Medicine. Investigators of the study aimed to determine whether daily toothbrushing could be associated with HAP and other patient outcomes, including mortality, length of stay, and duration of invasive mechanical ventilation.¹

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“The signal that we see here towards lower mortality is striking—it suggests that regular toothbrushing in the hospital may save lives,” Michael Klompas, MD, MPH, hospital epidemiologist and an infectious disease physician in the Department of Medicine at Brigham and Women’s Hospital, said in a press release. “It’s rare in the world of hospital preventative medicine to find something like this that is both effective and cheap. Instead of a new device or drug, our study indicates that something as simple as brushing teeth can make a big difference.”²

In the study, investigators combined results from 15 randomized clinical trials to conduct a systemic review examining the association between toothbrushing and HAP and patient outcomes.² Clinical trials from PubMed, Embase, Web of Science, and more were combined to find data included in the study.^1,2 The studies examined effects of regular oral care with toothbrushing compared to oral care without toothbrushing, including outcomes on HAP and other outcomes.² Study publication dates occurred from 2009 to 2022, with follow up of all studies varying from 5 to 28 days, or until diagnosis of pneumonia, extubation, or discharge, according to the study.¹

Investigators reported that in most studies, teeth were brushed 2 or 3 times daily, with ranges from 4 to 5 times per week to 4 times daily, according to the study authors. Among the study patients, there were 10,742 individuals, including those receiving mechanical ventilation (13 studies), those who were hospitalized without invasive mechanical ventilation (1 study), and patients in the ICU both receiving and not receiving mechanical ventilation (1 study). Investigators included 2786 individuals in the meta-analysis, according to the study authors.¹

The study authors reported that those who were brushing their teeth had significantly lower HAP rates, including ventilator-associated pneumonia and nonventilator-HAP.¹ Additionally, in 12 studies reporting on ventilator-associated pneumonia, toothbrushing was associated with lower rates of ventilator-associated pneumonia, which the authors said corresponded to a number needed to treat of 12 to prevent 1 ventilator-associated case.¹

Furthermore, in the trials with non-ventilator HAP, toothbrushing significantly reduced non-ventilator HAP in medical units, but not in surgical units, according to the results of the study. Toothbrushing was also associated with lower ICU mortality, less time to extubation, reduction in ventilation days, shorter ICU stays, according to the investigators.¹ Investigators also found no difference in total antibiotic days between the 2 groups. Because of the differences in the populations and due to high or unclear risk of bias, duration of hospitalization was not included in the meta-analysis.¹

“The findings from our study emphasize the importance of implementing an oral health routine that includes toothbrushing for hospitalized patients. Our hope is that our study will help catalyze policies and programs to assure that hospitalized patients regularly brush their teeth. If a patient cannot perform the task themselves, we recommend a member of the patient’s care team assist,” Klompas, said in the press release.²

References

1. Ehrenzeller S, Klompas M. Association Between Daily Toothbrushing and Hospital-Acquired Pneumonia: A Systematic Review and Meta-Analysis. JAMA Intern Med. Published online December 18, 2023. doi:10.1001/jamainternmed.2023.6638
2. Toothbrushing tied to lower rates of pneumonia among hospitalized patients. News release. EurekAlert. December 18, 2023. Accessed December 18, 2023. https://www.eurekalert.org/news-releases/1011253