Critical Care

, 23:382 | Cite as

Oral mucositis as a pathway for fatal outcome among critically ill patients exposed to chlorhexidine: post hoc analysis of a randomized clinical trial

  • Wanessa Teixeira Bellissimo-Rodrigues
  • Mayra Gonçalves Menegueti
  • Leandro Dorigan de Macedo
  • Anibal Basile-Filho
  • Roberto Martinez
  • Fernando Bellissimo-RodriguesEmail author
Open Access
Research Letter


Chlorhexidine Mucositis Mortality Respiratory tract infections Dental care Critical care 

Chlorhexidine (CHX) oral application has been widely used for preventing respiratory infections among critically ill patients, despite controversial effectiveness and the suspicion that it could enhance their mortality [1, 2, 3]. The physiopathology behind this association is poorly understood [2, 3]. Our objective was to reassess data from a clinical trial searching for potential pathways for the CHX-associated mortality [4, 5].

This is a post hoc analysis of a randomized clinical trial evaluating a dental care intervention aimed to prevent respiratory infections in the intensive care unit (ICU) setting. Adult patients admitted to the study ICU between January 1, 2011, and August 8, 2013, were eligible if they had a perspective of staying for 2 days. Participants were randomized by the dentist using a dice. The experimental group received dental care provided by a dentist plus routine oral care, while the control group had access only to routine oral care provided by the nursing staff. Both groups used 0.12% CHX oral solution, if fully conscious, or 2% CHX oral gel, if unconscious, three times a day throughout their ICU stay.

Adverse events potentially related to oral care procedures were pragmatically assessed at least three times a week in both study groups by the dentist during ICU stay. Their relationship with death in the ICU was evaluated through a logistic regression model, adjusting the outcome for sex, age, and Acute Physiology and Chronic Health Evaluation System II (APACHE II) score. Sample size was calculated based on the primary study outcome and the lower respiratory tract infection incidence and pointed to the inclusion of 294 patients.

Study “per protocol” population consisted of 254 patients and 9.84% (25/254) of them had adverse events related to oral care procedures, being the most common CHX-induced mucositis (7.09%, 18/254), consisting of oral erosive or ulcerative lesions, along with white plaque formation [6]. Only one patient had previous lesions before exposure to CHX. This adverse event was exclusively reported in patients exposed to 2% CHX oral gel (9.28%, 18/194, p = 0.006) and was found to be associated with a fatal outcome in both univariate and multivariate analysis, as shown in Table 1.
Table 1

Clinical and demographic characteristics of patients and occurrence of adverse events related to oral care procedures evaluated as potential risk factors for death during ICU stay

Clinical and demographic characteristics

Discharged alive

Death in the ICU

Crude RR (95%CI)

Adjusted OR (95%CI)

Adjusted p value


69.4 (84/121)

30.6 (37/121)


69.9 (93/133)

30.1 (40/133)

0.98 (0.68–1.43)

0.83 (0.45–1.52)


Age in years

57 (41–71)

62 (52–71)

1.02 (1.00–1.03)

1.00 (0.98–1.02)



20 (16–26)

27 (21–31)

1.10 (1.06–1.15)

1.10 (1.05–1.15)

< 0.001

Routine oral care

68.5 (87/127)

31.5 (40/127)

Dental treatment

70.9 (90/127)

29.1 (37/127)

0.92 (0.64–1.34)

0.92 (0.50–1.67)


Without adverse events related to oral care

73.4 (168/229)

26.6 (61/229)

With any adverse event related to oral care

36.0 (9/25)

64.0 (16/25)

2.40 (1.67–3.46)

5.46 (2.11–14.13)

< 0.001

Without CHX-induced mucositis

72.5 (171/236)

27.5 (65/236)

With CHX-induced mucositis

33.3 (6/18)

66.7 (12/18)

2.42 (1.64–3.56)

6.14 (1.98–19.08)


Without intraoral bleeding

71 (174/245)

29 (71/245)

With intraoral bleeding

33.3 (3/9)

66.7 (6/9)

2.30 (1.40–3.80)

3.74 (0.75–18.58)


Values expressed are % (n/N) of patients for categorical variables and median (interquartile range) for continuous variables

ICU intensive care unit, APACHE II Acute Physiology and Chronic Health Evaluation System II, RR relative risk, OR odds ratio

Most of the patients who died had infection and sepsis as their direct cause of death (56/77, 72.7%). Table 2 describes the occurrence of CHX-induced mucositis and its association with direct causes of death and temporal outcomes reported during ICU stay.
Table 2

Occurrence of CHX-induced mucositis and its association with direct causes of death and temporal outcomes reported during ICU stay


Without mucositis % (n/N)

With CHX-induced mucositis % (n/N)

RR (95%CI)

 Death, in general

27.5 (65/236)

66.7 (12/18)

2.42 (1.64–3.56)

 Death due to any infection

20.3 (48/236)

44.4 (8/18)

2.18 (1.23–3.88)

 Death due to respiratory infection

10.6 (25/236)

22.2 (4/18)

2.10 (0.82–5.37)

 Death due to intrabdominal infection

5.93 (14/236)

16.7 (3/18)

2.81 (0.89–8.88)

 Death due to acute respiratory failure

3.4 (8/236)

5.6 (1/18)

1.64 (0.22–12.39)

 Death due to cardiovascular events

2.5 (6/236)

0 (0/18)


Temporal outcome

Without CHX-induced mucositis

Median (interquartile range)

With CHX-induced mucositis

Median (interquartile range)

p valuea

 Duration of mechanical ventilation (days)

7 (3–16)

13 (8–20)


 Duration of antimicrobial therapy (days)

5 (2–11)

12.5 (8–18)


 Length of stay in the ICU (days)

7 (4–15)

14 (9–20)


ICU intensive care unit, RR relative risk

aWilcoxon (Mann-Whitney test)

In the present study, we could not assess whether CHX application enhanced or not the mortality of the studied patients because all of them were exposed to it. However, examining the adverse events potentially related to oral care procedures, we found the CHX-induced mucositis was strongly and independently associated with death, even when the association was adjusted for sex, age, and the patients’ baseline severity of illness score. Consistently, patients affected by CHX-induced mucositis had a prolonged length of stay in the ICU and mechanical ventilation and were submitted to longer periods of antimicrobial therapy. Of great concern is the fact that the interruption of the 2% CHX oral gel application after identification of mucositis did not prevent these patients to clinically deteriorate, eventually leading 2/3 (12/18) of them to die in the ICU.

In conclusion, our data points to oral mucositis as the main pathway for the association between CHX exposure and enhanced in-hospital mortality. The disruption of the oral mucosa integrity possibly leads to the translocation of bacteria from the oral cavity to the bloodstream, therefore enhancing the likelihood of infection and sepsis. In our opinion, the use of oral CHX among hospitalized patients should be strictly restricted to those with established intraoral infections, such as periodontal disease, preferentially applied by a dentist.



The authors thank the Intensive Care Team and the Infection Control Service of the study facility for supporting the study implementation.

Authors’ contributions

WTBR conceived the study, performed the literature review, collected most of the data, and wrote the first version of the manuscript. MGM collected some of the study outcomes, participated in the analysis of the data, and revised the final version of the manuscript. LDM participated in the analysis of the data and preparation and revision of the manuscript. ABF and RM participated in the planning and implementation of the study, analysis of the data, and revision of the final manuscript. FBR conceived the study and participated in all stages of its implementation, including planning, collecting data, analyzing data, and preparing and revising the manuscript. All authors read and approved the final manuscript.


The clinical trial was supported by Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), process no. 2010/51063-4, and Fundação de Apoio ao Ensino, Pesquisa e Assistência do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FAEPA), both non-profit organizations.

Ethics approval and consent to participate

The study protocol was submitted and approved by institutional (Comitê de Ética em Pesquisa do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto) and national ethics review committees before implementation. The protocol number was CAAE - 0490.0.004.000-09. Written consent was obtained from all participating patients, or from their relatives, in case of unconscious patients.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.


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© The Author(s). 2019

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Authors and Affiliations

  • Wanessa Teixeira Bellissimo-Rodrigues
    • 1
  • Mayra Gonçalves Menegueti
    • 2
  • Leandro Dorigan de Macedo
    • 3
  • Anibal Basile-Filho
    • 4
  • Roberto Martinez
    • 5
  • Fernando Bellissimo-Rodrigues
    • 1
    • 2
    Email author
  1. 1.Social Medicine Department, Ribeirão Preto Medical SchoolUniversity of São PauloRibeirão PretoBrazil
  2. 2.Infection Control Service, University Hospital of Ribeirão Preto Medical SchoolUniversity of São PauloRibeirão PretoBrazil
  3. 3.Dental Service, University Hospital of Ribeirão Preto Medical SchoolUniversity of São PauloRibeirão PretoBrazil
  4. 4.Intensive Care Medicine Division, Department of Surgery and Anatomy, Ribeirão Preto Medical SchoolUniversity of São PauloRibeirão PretoBrazil
  5. 5.Infectious Diseases Division, Internal Medicine Department, Ribeirão Preto Medical SchoolUniversity of São PauloRibeirão PretoBrazil

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