Professional Dental Care May Reduce the Incidence of Non--ventilator-associated Pneumonia in Hospitals and Chronic Care Settings

Subjects or Study SelectionTwo databases (Embase and PubMed) were systematically searched for studies investigating non-ventilator-associated pneumonia and oral care interventions through January 2019. To ensure literature saturation, supplementary literature searches and cross-referencing were carried out, along with manual searches of the bibliographies of included studies. Randomized and nonrandomized control trials, retrospective, prospective, and quasiexperimental studies conducted with human participants aged 18 years and older were included. Participants resided in long-term care facilities and hospital settings. Inclusion criteria included studies written in English with a primary outcome of non-ventilator-associated pneumonia (NVAP) and data provided in the form of point estimates with measures of 95% confidence interval (CI). Exclusion criteria included studies that did not differentiate between ventilator-associated pneumonia and NVAP, studies assessing participants with pneumonia on admission, studies that did not provide specific NVAP data, and studies that presented data only in abstract and poster format. Two investigators independently screened full texts before study inclusion and resolved discrepancies by discussion. The quality of included studies was independently assessed by the authors, and specifically, randomized control trials were assessed using the Cochrane Collaboration and observational studies were assessed using the Newcastle Ottawa Scale.Key Study FactorProvision of enhanced oral care compared with placebo, usual care, or comparable medication in long-term or hospital care settings was the key study factor.Main Outcome MeasureThe primary outcome was the incidence of NVAP in chronic or hospital care settings. The effects of oral care interventions on the incidence of NVAP was investigated in the included studies. Subgroup analyses were carried out to investigate the effect of chlorhexidine use, the effect of dental professional involvement in enhanced oral care, and the effect of enhanced oral care in the prevention of mortality.Main ResultsEleven studies were identified that met the inclusion criteria. Seven clinical trials, two nonrandomized clinical trials, 1 quasirandomized, and 1 retrospective cohort study were included. Seven studies were conducted in nursing homes, two in intensive care units, 1 in a stroke rehabilitation unit, and 1 in a neurosurgical population outside the critical care environment. A meta-analysis of randomized controlled trials (n = 6 studies, 1 excluded from analysis) performed using random effects model revealed no significant difference between enhanced and routine oral care in preventing the incidence of NVAP; RR of 0.89 (95% CI: 0.64-1.25), P = .50, and significant heterogeneity, I-2 = 65.2%. In subgroup analysis, chlorhexidine mouthwash had no effect on preventing NVAP compared with normal care (n = 3 studies); RR of 1.05 (95% CI, 0.69-1.60), P = .80, I-2 76.6%, (P = .01). In comparison, dental professional involvement in delivering enhanced oral care was found to reduce the risk of NVAP by 35% compared with routine care (n = 3 studies); RR 0.65 (95% CI, 0.43-0.98), P = .03, with no heterogeneity, I-2 = 0%. Enhanced oral care compared with normal care was found to have no effect in reducing NVAP-related mortality (n = 4 studies); RR 0.80 (95% CI, 0.40-1.63), P = .54, I-2 = 83%. Analysis of nonrandomized clinical trials, the retrospective study, and the quasiexperimental study showed no difference; RR 1.42 (95% CI, 0.70-2.88), 0.25 (95% CIs 0.06, 1.02) and OR 1.21 (95% CI 0.99-1.48), respectively.ConclusionsIn conclusion, this systematic review and meta-analysis showed that delivery of enhanced oral care by dental professionals significantly reduced the incidence of NVAP. The evidence was obtained from a small number of studies with significant heterogeneity.