Simple Way to Prevent Pneumonia During Hospital Stays: Study

A new study found that rates of hospital-acquired pneumonia were lower in patients who had their teeth brushed daily.

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Preventing pneumonia during hospital stays could be as simple as brushing a patient’s teeth, according to new research published in the Journal of the American Medical Association Internal Medicine.

A team led by Drs. Selina Ehrenzeller and Michael Klompas of Harvard Medical School and Brigham and Women’s Hospital in Massachusetts reviewed 15 randomized clinical trials of oral care regimens during hospital stays. The trials were conducted between 2009 and 2022 around the world and included 2,786 patients from Iran, Brazil, India, Spain, China, the United States, Malaysia, and Taiwan. In most studies, patients had their teeth brushed with chlorhexidine gluconate (11 studies) or a simple plaque-removing toothpaste two or three times daily, between four and five times a week. Patients had their teeth brushed either by dental professionals or nondental nursing staff.

The researchers found that rates of hospital-acquired pneumonia were lower in patients who had their teeth brushed daily, especially among patients who were on invasive mechanical ventilators. Additionally, those patients who had their teeth brushed spent less time on a ventilator, were in the intensive care unit (ICU) for shorter periods, and had a lower ICU mortality rate.

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“These findings suggest that daily toothbrushing may be associated with lower rates of pneumonia and ICU mortality,” the researchers wrote. “Programs and policies to encourage daily toothbrushing are warranted.”

However, toothbrushing did not reduce the length of hospital stay overall, the research team found.

Pneumonia’s Ties to Oral Health

According to the researchers, hospital-acquired pneumonia is the most common and deadliest infection associated with hospital stays. The U.S. Centers for Disease Control and Prevention (CDC) estimates that hospital-acquired pneumonia comprises most health care-associated pneumonia cases, with a mortality rate ranging from 15 percent to 30 percent. Hospital-acquired pneumonia is an infection of the lungs associated with symptoms that include mental changes or confusion, cough with sputum, fever and chills, general discomfort, loss of appetite, and sharp chest pain. It is diagnosed as hospital-acquired pneumonia if these symptoms occur at least 48 hours after hospital admission.

The illness can be spread by visitors or health care workers who can pass germs from their hands or clothes. It occurs more often among those on ventilators, the researchers pointed out. The reason, according to Dr. Rupak Datta, who wrote a commentary on the study, is often that patients on ventilators inhale a “highly diverse ecosystem with an estimated 700 species of bacteria, fungi, viruses, and protozoa.

“Extensive data from epidemiological, microbiological, and molecular studies have established a link between the oral microbiome, oral health, dental plaques, and periodontal disease and the development of pneumonia,” wrote Dr. Datta.

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Dental plaque forms within hours of brushing the teeth, according to the CDC, and will proliferate if not removed by brushing. The plaque contains pathogenic bacteria that can result in hospital-acquired pneumonia if not removed.

The study notes that toothbrushing is likely more effective than antiseptics at reducing germs associated with hospital-acquired pneumonia. The results parallel those of a 2016 U.S. Department of Veterans Affairs project in which standardized oral care was provided to veterans stationed in a hospital or long-term care. The Hospital-Acquired Pneumonia Prevention by Engaging Nurses (HAPPEN) project decreased pneumonia rates by 40 percent to 60 percent in participating hospitals and long-term care facilities and saved over $100,000 in direct health care costs over a year.

Toothbrushing Saves Lives and Money

The study results have been repeated throughout the country.

For example, the John Medical Center in Bixby, Oklahoma, saved $195,400 by preventing five cases of pneumonia during the first year of implementing a structured oral health care protocol.

In another case study, the Department of Veterans Affairs Medical Center in Salem, Virginia, piloted an oral health care program in 2016 and reduced hospital-acquired pneumonia rates by 92 percent, saving 13 lives and $2.84 million over 19 months.

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At Florida’s Orlando Regional Medical Center, hospital-acquired pneumonia rates were reduced by 85 percent in the medical unit and 56 percent in the surgical unit between 2018 and 2019 after the organization implemented an oral health care protocol.

“Oral care in hospitalized patients is a low risk, low-cost invention, which potentially reduces [hospital-acquired pneumonia] and leads to the additional benefits of improved oral health,” the CDC wrote.

Dr. Datta noted in his commentary that as studies and literature on hospital-acquired pneumonia evolve, “oral hygiene could assume an indispensable role akin to hand hygiene in the prevention and control of health care-associated infections.”