Comparison of foam swabs and toothbrushes as oral hygiene interventions in mechanically ventilated patients: a randomised split mouth study

Paola J Marino, Ailish Hannigan, Sean Haywood, Jade M Cole, Nicki Palmer, Charlotte Emanuel, Tracey Kinsella, Michael A O Lewis, Matt P Wise, David W Williams, Paola J Marino, Ailish Hannigan, Sean Haywood, Jade M Cole, Nicki Palmer, Charlotte Emanuel, Tracey Kinsella, Michael A O Lewis, Matt P Wise, David W Williams

Abstract

Introduction: During critical illness, dental plaque may serve as a reservoir of respiratory pathogens. This study compared the effectiveness of toothbrushing with a small-headed toothbrush or a foam-headed swab in mechanically ventilated patients.

Methods: This was a randomised, assessor-blinded, split-mouth trial, performed at a single critical care unit. Adult, orally intubated patients with >20 teeth, where >24 hours of mechanical ventilation was expected were included. Teeth were cleaned 12-hourly using a foam swab or toothbrush (each randomly assigned to one side of the mouth). Cleaning efficacy was based on plaque scores, gingival index and microbial plaque counts.

Results: High initial plaque (mean=2.1 (SD 0.45)) and gingival (mean=2.0 (SD 0.54)) scores were recorded for 21 patients. A significant reduction compared with initial plaque index occurred using both toothbrushes (mean change=-1.26, 95% CI -1.57 to -0.95; p<0.001) and foam swabs (mean change=-1.28, 95% CI -1.54 to -1.01; p<0.001). There was significant reduction in gingival index over time using toothbrushes (mean change=-0.92; 95% CI -1.19 to -0.64; p<0.001) and foam swabs (mean change=-0.85; 95% CI -1.10 to -0.61; p<0.001). Differences between cleaning methods were not statistically significant (p=0.12 for change in gingival index; p=0.24 for change in plaque index). There was no significant change in bacterial dental plaque counts between toothbrushing (mean change 3.7×104 colony-forming units (CFUs); minimum to maximum (-2.5×1010 CFUs, 8.7×107 CFUs)) and foam swabs (mean change 9×104 CFUs; minimum to maximum (-3.1×1010 CFUs, 3.0×107 CFUs)).

Conclusions: Patients admitted to adult intensive care had poor oral health, which improved after brushing with a toothbrush or foam swab. Both interventions were equally effective at removing plaque and reducing gingival inflammation.

Trial registration number: NCT01154257; Pre-results.

Keywords: Assisted Ventilation; Bacterial Infection; Pneumonia; Respiratory Infection.

Conflict of interest statement

This research was funded by Cardiff University and PJM was supported by a Walport Clinical Fellowship and obtained a research grant for consumables from a GSK-Oral and Dental Research Trust award. SAGE products gifted the toothbrushes and foam brushes used in this study.

Figures

Figure 1
Figure 1
Toothbrush (A) and foam swab (B) used in this study (SAGE products).
Figure 2
Figure 2
(A) Changes in plaque and gingival index (Silness and Löe) for patients 1–8 over a 7-day period using oral hygiene intervention either with a toothbrush (solid line) or foam swab (broken line). (B) Changes in plaque and gingival index (Silness and Löe) for patients 9–17, over a 7-day period using oral hygiene intervention either with a toothbrush (solid line) or foam swab (broken line). (C) Changes in plaque and gingival index (Silness and Löe) for patients 19–28, over a 7-day period using oral hygiene intervention either with a toothbrush (solid line) or foam swab (broken line).
Figure 2
Figure 2
Continued
Figure 3
Figure 3
Box plots of change in gingival index (from baseline) for each study day. Asterisks represent extreme outliers >3 IQR; circles represent outliers >1.5 IQR.

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