One more reason to brush your teeth?

Three bright green, pink and blue toothbrushes showing blue and white bristles close-up on orange and yellow background

Maybe we should add toothbrushes to the bouquets we give to friends and family in the hospital—and make sure to bring one if we go to the hospital ourselves.

New Harvard-led research published online in Journal of the American Medical Association Internal Medicine Studies show that if critically ill hospitalized patients brush their teeth twice a day, they are significantly less likely to develop hospital-acquired pneumonia. They also required less time on a respirator, were able to leave the intensive care unit (ICU) sooner, and were less likely to die in the ICU than patients without similar tooth-brushing habits.

Why does brushing your teeth make a difference?

It makes sense that brushing your teeth would remove bacteria that can cause a lot of bad consequences,” said Dr. Tien Jiang, a lecturer in oral health policy and epidemiology at Harvard School of Dental Medicine who was not involved in the new study. “Plaque on teeth is very sticky, and rinsing alone cannot effectively remove the bacteria. Only brushing can do that.”

Pneumonia has been one of the main infections that occur during hospitalization. According to the Agency for Healthcare Research and Quality, more than 633,000 Americans each year go to the hospital for treatment for other health problems and end up with pneumonia. The air sacs (alveoli) in one or both lungs fill with fluid or pus, causing coughing, fever, chills, and difficulty breathing. Nearly 8% of patients with nosocomial pneumonia die from the disease.

How is the research conducted?

The researchers reviewed 15 randomized trials involving nearly 2,800 patients. All studies compared outcomes in critically ill hospitalized patients who brushed their teeth daily with those who did not.

  • 14 of the studies were conducted in the ICU
  • 13 patients requiring respirators
  • 11 An antiseptic rinse called chlorhexidine gluconate was used in all patients: those who brushed their teeth and those who did not.

what's the result?

Dr. Chiang said the findings are compelling and should spur efforts to standardize twice-daily toothbrushing for all hospitalized patients.

Study participants who were randomly assigned to brush their teeth twice a day were 33% less likely to develop hospital-acquired pneumonia. These effects are amplified for people who use respirators, who will need this invasive respiratory assistance for a shorter period of time if they brush their teeth.

Overall, study participants who took the twice-daily oral regimen were 19% less likely to die in the ICU and were able to graduate from the intensive care unit faster.

The length of stay or whether patients received antibiotics did not appear to affect the incidence of pneumonia. Additionally, brushing three or more times a day provides no additional benefits over brushing twice a day.

What are the strengths and limitations of this study?

A major advantage, Dr. Jiang said, is compiling years of small studies into one large analysis — something that's particularly unusual in dentistry. “From a dental perspective, doing 15 randomized controlled trials is huge. It's difficult to bring together such a large dental population at such a high level of evidence,” she said.

But brushing techniques may vary between the hospitals participating in the study. Although the study was randomized, it could not be blinded – a strategy that reduces the chance of biased results. Since brushing habits cannot be hidden, participating clinicians may have known that their brushing behavior was being tracked, which may have changed their behavior.

“Maybe they are more vigilant because of it,” Dr. Jiang said.

How does brushing your teeth prevent hospital-acquired pneumonia?

It's not complicated. Pneumonia in hospitalized patients often results from the inhalation of bacteria into the mouth, which include more than 700 different species of bacteria, fungi, viruses and other microorganisms.

This prospect is even more pronounced for patients who require ventilation, because a breathing tube inserted into the throat can carry bacteria deeper into the airway. “Ventilation patients lose their normal way of getting rid of certain bacteria,” Dr. Jiang said. “Without a ventilator, we can remove it from the upper airway.”

How important is brushing your teeth if you're not in the hospital?

If you think the study results only apply to people in hospitals, think again. Rather, it drives home how important it is for everyone to take care of their teeth and gums.

Approximately 300 diseases and conditions are related in some way to oral health. Poor oral health can cause some health problems and worsen others. For example, people with gum disease and tooth loss have a higher chance of having a heart attack. Those with uncontrolled gum disease often have more difficulty controlling blood sugar levels.

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