Oral hygiene care for critically ill patients to prevent ventilator‐associated pneumonia

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• it is important, that during oral hygiene care for critically ill patients in ICUs, the plaque and debris are removed from the oral cavity with care by trained healthcare professionals, in order to avoid aspiration of contaminated fluids into the respiratory tract. Raising the head of the bed, and careful use of appropriately‐maintained closed suction systems, together with an appropriately‐fitted cuff around the endotracheal tube are other important aspects of care of critically ill patients that are not part of this systematic review.

• Routine oral hygiene care is designed to remove plaque and debris, as well as replacing some of the functions of saliva, moistening and rinsing the mouth. Toothbrushing, with either a manual or powered toothbrush, removes plaque from teeth and gums and disrupts the biofilm within which plaque bacteria multiply (Whittaker 1996; Zanatta 2011). It is hypothesised that using an antiseptic, such as chlorhexidine gluconate or povidone iodine, as either a rinse or a gel, may further reduce the bacterial load or delay a subsequent increase in bacterial load.

• VAP is generally defined as a pneumonia developing in a patient who has received mechanical ventilation for at least 48 hours

• Dental plaque accumulates rapidly in the mouths of critically ill patients and as the amount of plaque increases, colonisation by microbial pathogens is likely (Fourrier 1998; Sands 2016; Scannapieco 1992). Plaque colonisation may be exacerbated in the absence of adequate oral hygiene care and by the drying of the oral cavity due to prolonged mouth opening, which reduces the buffering and cleansing effects of saliva. In addition, the patient's normal defence mechanisms for resisting infection may be impaired (Alhazzani 2013; Terpenning 2005). Dental plaque is a complex biofilm which, once formed, is relatively resistant to chemical control, requiring mechanical disruption (such as toothbrushing) for maximum impact

• Micro‐aspiration of pharyngeal secretions may also occur around an imperfect seal of the cuff of the endotracheal tube in a ventilated patient. Several studies have shown that micro‐aspiration contributes to the development of nosocomial pneumonia

• As the overuse of systemic antibiotics may be associated with the development of multidrug‐resistant pathogens, there is merit in using other approaches to prevent infections such as VAP.

• Oral hygiene care includes the use of mouthrinse, gel, swab or toothbrushing (either manual or powered) etc. to remove plaque and debris from the oral cavity. Oral hygiene care also involves suction to remove excess fluid, toothpaste, and debris, and may be followed by the application of an antiseptic gel. Antiseptics are broadly defined to include saline, chlorhexidine, povidone iodine, cetylpyridium, and possibly others (but exclude antibiotics).

• Diagnostic criteria for the outcome of ventilator‐associated pneumonia were specified in 37 studies. Seventeen studies used Pugin's criteria (Cook 1998; Pugin 1991), which form the basis of the CPIS score, based on the presence of an infiltrate on chest radiograph, plus two or more of the following: temperature greater than 38.5º C or less than 35º C, white blood cell count greater than 11,000/mm3 or less than 4000/mm3, mucopurulent or purulent bronchial secretions, or more than 20% increase in fraction of inspired oxygen required to maintain saturation above 92%