Tooth Brushing vs Chlorhexidine in Decreasing VAP Risks

For most patients in intensive care units who require endotracheal intubation or mechanical ventilation, ventilator associated pneumonia, or VAP, is the most common nosocomial infection. The chance of VAP occurrence ranges from 1 to 3 percent for every day a patient is mechanically ventilated. However, these rates vary depending on the type of ICU, diagnostic criteria, and research group. Pathogens enter the respiratory tract of the patients when aspiration of contents from the oropharynx as well as the secretions which may have accumulated above the endotracheal tube cuff as a result of oral microorganisms emanating from the dental cavities thus coming to colonize the trachea and the oropharynx (Clerehugh et al.,2009). The endotracheal tubes facilitate the conduction of micro-organisms from the oropharynx to the lower section of the respiratory tract, these have been identified as the primary agents resulting in nosocomial anemia, and therefore being able to interrupt the process by halting the colonization by bacteria represents the first step in the prevention of VAP.

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When determining the rate of infections acquired by a patient while in the intensive care unit, 9 to 40 percent of the infections are attributed to the ventilator associated pneumonia. These infections are directly related to the increased period of stay in the hospital as well as high morbidity and mortality rates. Oral hygiene is considered very important in decreasing the risks from ventilator associated pneumonia. However, there has been no clear guideline provided on how to perform oral hygiene which has resulted in the different hygienic practices which we have today. For patients who need critical care or those in the intensive care unit, chlorhexidine is utilized as an oral antiseptic which helps with the reduction of dental plaque (Gulanick & Myers, 2014). Its action reduces the load of pathogens present in the plaque and the process reducing VAP rates. Tooth brushing is another manual method used to clean dental cavities thus reducing the pathogenic load.

A present study aimed at evaluating the effects of using chlorhexidine and manual brushing on oral hygiene on a heterogeneous population consisting of patients in intensive care units concluded that, for those using 0.12% of chlorhexidine, the occurrence of ventricular associated pneumonia decreased by almost 30% for those patients undergoing heart surgery. This, of course, was also based on the duration of the mechanical ventilation as well as the length of stay in the ICU and the hospital in general for over six months. Using chlorhexidine, in this case, helped reduce the occurrence of HAP for the patients (Needleman et al., 2011). Also given the fact that microbiota, present in the oral cavity plays a significant role in the development of ventricular associated pneumonia, some studies suggest that a topical application of chlorhexidine before intubation does reduce the prevalence of nosocomial infections in such patients (El-Rabbany et al.,2015).

Even though, controlling the bacterial plaque pharmacologically by using chlorhexidine is widely accepted and practiced by most health professionals, the effect achieved by using the chemical approach against accumulated bacterial plaque is very marginal. This is because the plaque represents a biofilm (Vidal et al., 2017). The bacterium is therefore considerably less sensitive to the chemical used as a form of microbial therapy if compared to a freely moving planktonic form (Lakade et al., 2014). Therefore, it is safe to presume that mechanical cleansing using a tooth brush could be the best and efficient method of getting rid of the pathogens from the plaque also including the multi resistant anaerobes and bacteria, for instance, methicilline-resistant Staphylococcus aureus. On the other hand, for the patients who have been intubated, manual cleansing using a tooth brush by the caregiver instead of the patient himself, might lead to an increase in the risk of VAP and other adverse effects, something which is contrary to the expectations.

Other than that, it is highly possible tooth brushing may result in bleeding gums as well as the breakage of the mucosal barrier which ends up allowing entry of pathogens and more bacteria emanating from the dental plaque into the blood stream which in turn increases the rate of VAP related infections. Furthermore, not being able to control the cuff pressure of the endotracheal tube during or after brushing your teeth, may end up increasing the chances of micro-aspiration (Graziani et al., 2015). Contrary to the use of chlorhexidine, when performing this form of oral hygiene, care must be taken to ensure that the pressure of the cuff is controlled and monitored. Failure to do so increase VAP risks to about 60% while VAP rate decreases by almost 50% if performed correctly. It is therefore clear, the fundamental role played by the oral cavity regarding the colonization of the oropharynx with pathogens as well as the compromises to oral immunity due to lack of oral hygiene which ends up facilitating the formation of biofilm (Lorente et al., 2012)

This, however, does not rule out the fact that mechanical removal of the pathogens can lead to an increased efficacy regarding the effects of using chlorhexidine to clean out the remaining bacteria. However, it does appear that oral hygiene which involves the use of chlorhexidine or tooth brushing single handily cannot be able to decrease the risks ventricular associated pneumonia in heterogeneous populations consisting of severe illnesses, intubated patients and thus needs to be addressed by combining them with other relevant preventive measures (Alhazzani et al., 2013). When this is completed, we find that the level of VAP infections reduces significantly by 89%. One such preventive measure could be the use of toothbrushes, chlorhexidine, hand antiseptics as well as daily evaluation of intubation.

Conclusion

Even though most studies seem to suggest a potential relationship between increased incidences of VAP and the deficiency in oral hygiene, there is insufficient evidence to prove that. Toothbrushing remains the primary basis for getting rid of dental plaque which consequently leads to a reduction in a load of bacteria thus reducing the risks of VAP. Other studies on patients who went through myocardial revascularization surgeries showcased a 58% decrease in VAP rates using 0.12% chlorhexidine. Controversy, however, comes in observed situations where even though chlorhexidine is able to reduce the number of pathogens within the oral cavity, the reduction was not sufficient enough to decrease VAP rates (Muniz et al., 2015). Whether tooth brushing or using chlorhexidine respectively is effective in reducing VAP risks, the best and safest way would be to combine these practices when observing a patient’s oral hygiene in order to minimize the risks from all corners.

In addition to that, another ideal way would be making use of more precise measurements when dealing with such kind of patients to validate oral cleansing techniques. Something which to a great extent has complicated the interpretation of results regarding ventricular associated pneumonia is the diagnostic complexity which leaves room for higher bias probability. However, as most results obtained show that there was a significant reduction regarding the duration and risk of VAP for patients who used tooth brushing, it stands a better chance of decreasing the risks of ventricular associated pneumonia compared to the use of chlorhexidine.

References

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Graziani, F., Gabriele, M., D’Aiuto, F., Suvan, J., Tonelli, M., & Cei, S. (2015). Dental Plaque, Gingival Inflammation and Tooth Discolouration with Different Commercial Formulations of 0.2% Chlorhexidine Rinse: A Double-blind Randomised Controlled Clinical Trial. Oral health & preventive dentistry, 13(2).

Gulanick, M., & Myers, J. L. (2014). Nursing care plans: Diagnoses, interventions, and outcomes. Philadelphia: Elsevier/Mosby.

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Needleman, I. G., Hirsch, N. P., Leemans, M., Moles, D. R., Wilson, M., Ready, D. R., . . .

Wilson, S. (2011). Randomized controlled trial of toothbrushing to reduce ventilator-associated pneumonia pathogens and dental plaque in a critical care unit. Journal of Clinical Periodontology, 38(3), 246-252. doi:10.1111/j.1600-051x.2010.01688.

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Lacerda, H. R. (2017). Erratum to: Impact of oral hygiene involving toothbrushing versus chlorhexidine in the prevention of ventilator-associated pneumonia: a randomized study. BMC Infectious Diseases, 17(1). doi:10.1186/s12879-017-2273-4