Running head: THE USE OF ORAL CARE IN PREVENTING VEN

The Use of Oral Care in Preventing Ventilator Associated Pneumonia

Nina Wilczynski
University of South Florida

THE USE OF ORAL CARE IN PREVENTING VEN

Abstract
Clinical problem: Poor oral health is a risk factor to lower respiratory tract infections and can
contribute to the acquisition of ventilator associate pneumonia (VAP) (Grap et al., 2011).
Objective: The purpose of this paper is to compare two different dental health interventions in
the prevention of VAP, a chlorhexidine oral rinse or mechanical teeth brushing. The search
engines used to find clinical guidelines and research include Pubmed, CINAHL, and the National
Guidelines Clearinghouse (NGH). The central vocabulary used to search for evidence included
oral health, ventilator associated pneumonia, oral care, dental health, oral hygiene, and dental
hygiene.
Results: The clinical guidelines recommend oral care with the use of a chlorhexidine mouth rinse
as part of a VAP prevention bundle (Institute for Clinical Systems Improvement [ICSI], 2011).
Bellissimo-Rodrigues et al. (2014) reported that an oral care intervention bundle that included
mechanical teeth brushing significantly lowered VAP rates in the experimental group as
compared to the control group that only received standardized dental care with a chlorhexidine
mouth rinse (p<.05). Grap et. al (2010) reported that a single early application of chlorhexidine
in the experimental group reduced CPIS scores at 48 hours (p=.020) and 72 hours (p=.027) as
compared to the control group that did not receive a chlorhexidine rinse after intubation. Yao,
Chang, Maa, Wang, and Chen (2010) reported that mechanical teeth brushing twice daily in the
experimental group produced lower CPIS scores as compared to standardized oral care using
foam swabs (p<.001).
Conclusion: Both mechanical teeth brushing and chlorhexidine have been reported as effective
interventions in the prevention of VAP.

THE USE OF ORAL CARE IN PREVENTING VEN

The Use of Oral Care in Preventing Ventilator Associated Pneumonia

Ventilator associated pneumonia (VAP) is a possible complication for patients who are on
a ventilator. In patients who are intubated, the physiological barrier of the epiglottis to the
trachea is breached. The opening of the lower respiratory tract through intubation leads to the
movement of infectious bacteria down the respiratory tract (Grap et al., 2011). Patients who have
poor oral health are shown to be 1.3 times more likely to contract a respiratory disease (Yao,
Chang, Maa, Wang, Chen, 2011). Logically, preventative measures would include methods to
prevent the movement of bacteria down the tract. In patients who have been place on a ventilator,
how does mechanical teeth brushing compare to the use of a chlorhexidine oral rinse in the
prevention of ventilator associated pneumonia over a period of 3 months?
Literature Search
Pubmed, CINAHL and the National Guidelines Clearinghouse (NGH) were the search
engines used to retrieve clinical trials and guidelines. The key search terms used included
ventilator associated pneumonia, oral care, oral health, oral hygiene, dental health, and dental
hygiene. The search was further narrowed down by using only peer reviewed randomized
controlled trials from the past five years conducted on humans and written in English.
Literature Review
Bellissimo-Rodrigues et al. (2014) compared the effectiveness of two different oral care
interventions in the prevention of VAP. Patients in the ICU were randomly assigned to two
groups. The experimental group received routine dental care through a dental surgeon 4-5 times a
week. That dental care included teeth brushing, tongue scraping, the removal of calculus,
restorative treatment of dental caries and tooth extraction. The control group received routine
oral care through the use of a chlorhexidine rinse twice daily. The sample included 254 adults

THE USE OF ORAL CARE IN PREVENTING VEN

that stayed in the ICU for at least 48 hours. The sample size was 127 for both groups. All patients
had no history of pregnancy, no blood disorders and no preexisting pneumonia. Outcome
measures included incidence of VAP during hospital stay, duration of ventilation, and length of
stay in the ICU. Results showed a VAP rate per 1,000 ventilator days of 16.5 in the control group
as compared to 7.6 in the experimental group (p<.05).
Strengths for this study include the following: adults were randomly assigned to the
control or intervention group, the individuals responsible were blinded to the intervention
groups, the rationale for why adults did not finish the study was given, measuring VAP rates
during stay, duration of ventilation and length of stay in the ICU was valid and reliable, patients
were evaluated in the group they were initially randomly assigned to, follow-up evaluations were
performed for a sufficient amount of time to wholly study the side effects of the intervention, the
control group was appropriate, and adults were similar in both groups in regards to baseline
variables. Limitations to this study include the following: patients were not blind to the study
groups, random assignment was not concealed from the dental surgeon who was first enrolling
subjects into the study, and adults were not similar in both groups in regards to demographics.
Grap et. al (2011) studied the effectiveness of a single application of chlorhexidine in
VAP prevention. The experimental group received a chlorhexidine mouth rinse within twelve
hours of intubation whereas the control group received no chlorhexidine rinse. One hundred and
forty five trauma patients made up the sample size; n=71 in the experimental group and n=74 in
the control group. The patients had no history of reintubation within 48 hours and did not have
pneumonia or burn injuries at the time of intubation. The outcome was measured through VAP
rates determined by a CPIS score greater than six. The results reported a reduction in CPIS

THE USE OF ORAL CARE IN PREVENTING VEN

scores in the experimental group at 48 hours (p=.020) and 72 hours (p=.027) as compared to the
control group that did not have a statistically significant reduction in CPIS scores.
Strengths for this study include the following: adults were randomly assigned to the
control or intervention group, random assignment was concealed from the individuals first
enrolling subjects into the study, patients and researchers evaluating outcome measures were
blind to the study, reasons why adults did not complete the study were given, follow-up
assessments were conducted long enough to fully study the side effects of the intervention, the
subjects were analyzed in the group to which they were randomly assigned, the control group
was appropriate, and CPIS scores are a valid and reliable measuring instrument. Limitations to
this study include: nurses performing the interventions were not blind to the study group and
adults were not similar in both groups in regards to baseline variables and demographics.
Yao et al. (2011) studied the effectiveness of teeth brushing in decreasing VAP. Patients
admitted to the ICU who were expected to be intubated for more than 48 hours and who did not
previously have pneumonia were assigned to either the experimental or the control group. Both
groups receive hospital standardized oral care with a cotton swab brush. Patients in both groups
also had the head of their beds raised to 30-45 and received hypopharyngeal suctioning after
oral care. In addition to the standardized procedures, the experimental group also received oral
care twice daily via teeth brushing. Sample size included 58 adult patients; n=25 for the control
group and n=28 for the experimental group. A CPIS score of greater than 6 determined VAP rates
in either group. The results of the study showed a VAP incidence rate of 71% in the control group
as compared to 17% in the experimental group (p< 0.001).
Strengths of this study include: adults were randomly assigned to the control or
intervention group, random assignment was concealed from the individuals first enrolling

THE USE OF ORAL CARE IN PREVENTING VEN

subjects into the study, a dental hygienist evaluating outcome measures was blinded to the study,
reasons why adults did not complete the study were given, the subjects were analyzed in the
group to which they were randomly assigned, the control group was appropriate, CPIS scores,
OAG scores and plaque index scores were valid and reliable outcome measure instruments,
adults were similar in both groups in regards to baseline variables and demographics. Limitations
to this study include: patients were not blind to the study group, and follow-up assessments were
not conducted long enough to fully study the side effects of the intervention.
The NGC provides a guideline that recommends the use a of chlorhexidine rinse as a
VAP prevention intervention to be used in conjunction with other interventions in a VAP bundle
(ICSI, 2011). Mechanical teeth brushing is not a part of the recommended guideline.
Synthesis
All three research studies vary in the interventions they found to be effective in
preventing VAP. Bellissimo-Rodrigues et al. (2014) found that the use of an oral intervention
bundle that includes mechanical teeth brushing, restorative treatment of dental cavities, the
removal of calculus, tongue scraping, and tooth extraction was statistically more significant in
reducing VAP rates per 1000 ventilator days as compared to a twice daily chlorhexidine rinse
(p<.05). However, this study does not directly compare teeth brushing to a chlorhexidine rinse. It
is not possible to know if another intervention included in the oral care bundle was most
effective in preventing VAP. Grap et al. (2010) reported that the early use of chlorhexidine in
intubation lowers CPIS scores at 48 hours (p=.020) and 72 hours (p=.027) as compared to the
control group that did not receive chlorhexidine. Yao et. al. (2011) supports the use of
mechanical teeth brushing as it significantly lowered CPIS scores in patients compared to oral
care using foam swabs (p< 0.001). The NGC does not include mechanical teeth brushing as a

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guideline for VAP prevention, but does suggest the use of a chlorhexidine mouth rinse. More
randomized clinical trials are needed to directly compare teeth brushing to a chlorhexidine rinse
in VAP prevention.
Clinical Recommendations
Based on the results of the above randomized clinical trials, mechanical teeth brushing
should be included as a guideline intervention in the prevention of VAP. Currently, a
chlorhexidine rinse is included in the NGC guidelines for VAP prevention. In order to promote
evidenced based practice in nursing, teeth brushing as well as chlorhexidine should be
considered as a recommended intervention in VAP prevention.

THE USE OF ORAL CARE IN PREVENTING VEN

References
Bellissimo-Rodrigues, W. T., Menegueti, M. G., Gaspar, G. G., Nicolini, E. A., AuxiliadoraMartins, M., Basile-Filho, A., Bellissimo-Rodrigues, F. (2014). Effectiveness of a
dental care intervention in the prevention of lower respiratory tract nosocomial infections
among intensive care patients: A randomized clinical trial. Infection Control of Hospital
Epidemiology, 35, 1342-1348. doi: 10.1086/591478
Grap, M. J., Munro, C. L., Hamilton, V. A., Elswick, R. K., Sessler, C. N., Ward, K. R. (2011).
Early, single chlorhexidine application reduces ventilator-associated pneumonia in
trauma patients. Heart & Lung: The Journal of Critical Care, 40, 115-122. doi:
http://dx.doi.org/10.1016/j.hrtlng.2011.01.006
Institute for Clinical Systems Improvement (ICSI) (2011). Prevention of ventilator-associated
pneumonia. Health care protocol. Bloomington (MN): Institute for Clinical Systems
Improvement (ICSI)
Yao, L., Chang C., Maa, S., Wang, C., & Chen, C. C. (2011). Brushing teeth with purified water
to reduce ventilator-associated pneumonia. Journal of Nursing Research, 19, 289-297.
doi: 10.1097/JNR.0b013e318236d05f