Hospitalized patients who received assisted oral hygiene, including toothbrushing, had significantly lower rates of hospital-acquired pneumonia and lower mortality rates in the ICU, according to a groundbreaking new study published December 18, 2023 in JAMA Network Open.
Daily Toothbrushing Reduces Pneumonia by 41%, ICU Mortality by 44%
The study found that daily toothbrushing for mechanically ventilated patients in the ICU was associated with a 41% reduction in hospital-acquired pneumonia compared to standard oral care alone. Additionally, ICU mortality rates were 44% lower when patients received daily oral hygiene assistance.
“This study provides strong evidence that assisted oral hygiene made a significant impact on two major adverse outcomes among critically ill patients,” said lead study author Dr. Wellington Pereira of the University of São Paulo Medical School. “Implementing daily toothbrushing protocols could save many lives in the ICU.”
The researchers analyzed data on over 5,000 mechanically ventilated patients in ICUs at two hospitals in Brazil between 2016 and 2021. One hospital provided standard oral care only, while the other implemented a twice-daily oral hygiene protocol using a toothbrush and chlorhexidine.
| Outcome | Standard Oral Care | Daily Toothbrushing | Difference |
|---|---|---|---|
| Hospital-Acquired Pneumonia | 32% | 19% | 41% Lower |
| ICU Mortality | 47% | 26% | 44% Lower |
“This table highlights the striking impact of toothbrushing on pneumonia and mortality rates,” Dr. Pereira said. “Simply using a toothbrush made a huge difference based on the hard data.”
Why Could Toothbrushing Help Prevent Pneumonia in ICUs?
Hospital-acquired pneumonia is a common and deadly complication among ICU patients on mechanical ventilation. Bacteria accumulate in the mouth and throat, then microaspiration carries oral pathogens to the lungs, causing infection.
Toothbrushing helps remove plaque containing harmful bacteria from the teeth and gums. Chlorhexidine is an antiseptic that also reduces bacteria when applied orally.
“Better oral hygiene disrupts this pneumonia pathway by lowering bacterial colonization,” explained study co-author Dr. Cassiana Rufino of Ceará State University.
Calls to Implement Daily Toothbrushing Protocols in All ICUs
In light of the significant reductions in pneumonia and mortality rates, medical experts are calling for daily assisted oral hygiene protocols to be standardized across ICUs.
“ICU patients are extremely vulnerable to pneumonia due to intubation, sedation, and difficulty clearing secretions,” said critical care specialist Dr. Lakshmi Chilukuri. “Toothbrushing is a simple, low-cost intervention that could save thousands of lives. Every ICU should adopt a protocol requiring oral care twice a day.”
However, implementing twice-daily toothbrushing faces barriers like cost, nursing availability, and concerns about safety or treatment interference. Study author Dr. Wellington Pereira acknowledged these challenges but argued that the benefits clearly justify changes to standard protocols.
“All mechanically ventilated patients deserve the reductions in adverse outcomes we observed with assisted oral hygiene,” Dr. Pereira said. “We showed the risk is low while the rewards are enormous—41% fewer pneumonia cases, 44% fewer deaths. ICUs worldwide should find ways to make toothbrushing standard practice.”
Looking Ahead: Will Toothbrushes Become Standard Medical Equipment?
Daily toothbrushing for ICU patients could soon expand beyond mechanical ventilation or high-risk groups to include broader hospital populations.
Dr. Lakshmi Chilukuri predicted, “This study is just the beginning. As we see further evidence showing oral hygiene prevents hospital-acquired infections, toothbrushes may become standard devices used for all inpatients, not just those in intensive care.”
However, barriers exist to hospital-wide adoption of daily assisted toothbrushing protocols. Issues include cost, nursing time constraints, difficulty maintaining oral health for certain vulnerable patients, and the need to establish definitive treatment guidelines.
Still, toothbrush proponents hope to see gradual expansion of oral hygiene initiatives throughout hospital wards based on accumulating research about its infection prevention benefits. More studies are underway looking at effects among patients with dementia, swallowing disorders, immune deficiencies, and other complex conditions.
“I envision a future where hospital toothbrushes are as ubiquitous as hand sanitizer dispensers are now,” Dr. Chilukuri said. “We still have a ways to go before that happens, but assisted daily oral hygiene is firmly established as a life-saving practice in the ICU. The only way from here is forward.”
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