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Prevention of Healthcare-Associated Pneumonia with Oral Care in Individuals Without Mechanical Ventilation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Published online by Cambridge University Press:  10 April 2015

Asako Kaneoka*
Boston University Sargent College, Boston, Massachusetts
Jessica M. Pisegna
Boston University Sargent College, Boston, Massachusetts
Keri V. Miloro
Boston University Sargent College, Boston, Massachusetts
Mel Lo
South Shore Hospital, Weymouth, Massachusetts
Hiroki Saito
University of California Irvine School of Medicine, Department of Medicine, Division of Infectious Diseases, Irvine, California
Luis F. Riquelme
New York Medical College School of Health Sciences and Practice, Valhalla, New York, and New York Methodist Hospital, Brooklyn, New York
Michael P. LaValley
Boston University School of Public Health, Boston, Massachusetts
Susan E. Langmore
Boston University Sargent College, Boston, Massachusetts
Address correspondence to Asako Kaneoka, Boston University Medical Center, FGH building, 820 Harrison Ave., Boston, MA 02118 (



Evidence is lacking on the preventive effect of oral care on healthcare-associated pneumonia in hospitalized patients and nursing home residents who are not mechanically ventilated. The primary aim of this review was to assess the effectiveness of oral care on the incidence of pneumonia in nonventilated patients.


We searched 8 databases (MEDLINE, Embase, CENTRAL, CINAHL, Web of Science, LILACS, ICHUSHI, and CiNii), in addition to trial registries and a manual search. Eligible studies were published and unpublished randomized controlled trials examining the effect of any method of oral care on reported incidence of pneumonia and/or fatal pneumonia. Relative risks (RR) and 95% confidence intervals were calculated. Risk of bias was assessed for eligible studies.


We identified 5 studies consisting of 1,009 subjects that met the inclusion criteria. Of these, 2 trials assessed the effect of chlorhexidine in hospitalized patients; 3 studies examined mechanical oral cleaning in nursing home residents. A meta-analysis could only be done on 4 trials; this analysis showed a significant risk reduction in pneumonia through oral care interventions (RRfixed, 0.61; 95% CI, 0.40–0.91; P=.02). The effects of mechanical oral care alone were significant when pooled across studies. (RRfixed, 0.61; 95% CI, 0.40–0.92; P=.02). Risk reduction for fatal pneumonia from mechanical oral cleaning was also significant (RRfixed, 0.41; 95% CI, 0.23–0.71; P=.002). Most studies had a high risk of bias.


This analysis suggests a preventive effect of oral care on pneumonia in nonventilated individuals. This effect, however, should be interpreted with caution due to risk of bias in the included trials.

Infect Control Hosp Epidemiol 2015;36(8): 899–906

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© 2015 by The Society for Healthcare Epidemiology of America. All rights reserved 

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Prevention of Healthcare-Associated Pneumonia with Oral Care in Individuals Without Mechanical Ventilation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
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