Abstract

Background: Ventilator-associated pneumonia (VAP) is a common complication in ventilated patients. The endotracheal tube acts as a conduit for oral cavity pathogenic bacteria into the lungs due to an imperfect cuff seal. Oral hygiene is designed to remove plaque and debris where bacteria multiply, reducing the risk of ventilator-associated pneumonia.Aims: To assess the comparative effects of oral hygiene agents and modalities on VAP incidence in critically ill mechanically ventilated patients and to assess their relative ranking according to their effects.Study Design: Systematic review and network meta-analysis (PROSPERO registration CRD42021259690). We retrieved randomized controlled trials using oral hygiene pro-cedures from a recent Cochrane review and updated the search to December 2021. Results: We included 30 RCTs with 3980 participants. Some interventions, such as miswak and nanosil, may result in a large decrease in VAP incidence (miswak RR 0.05, 95% CI 0.00-1.21; nanosil RR 0.08, 95% CI 0.01-0.88), but some confidence intervals include substantial benefits and harms. Powered toothbrushing and manual tooth-brushing may result in a large decrease in VAP incidence (powered toothbrushing RR 0.55, 95% CI 0.30-1.00; manual toothbrushing RR 0.65, 95% CI 0.40-1.04); however, the confidence intervals may indicate little to no significant difference. The certainty of the evidence was mostly low due to the small sample size and risk of bias.Conclusions: Low-certainty evidence indicates that miswak and nanosil may reduce VAP incidence. Moreover, toothbrushing may also reduce VAP incidence and mortal-ity. High-quality RCTs are needed to establish the relative effectiveness of these interventions.