Effects of differences in perioperative mouthwash on oral bacteria and postoperative complications: Sub-analysis of a mouthwash intervention study

doi:10.21203/rs.3.rs-5304776/v1

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Effects of differences in perioperative mouthwash on oral bacteria and postoperative complications: Sub-analysis of a mouthwash intervention study

https://doi.org/10.21203/rs.3.rs-5304776/v1

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Background

Perioperative oral management (POM) reduces the risk of postoperative complications. We previously conducted a randomized controlled feasibility study of POM using povidone iodine (PVP-I) or 0.05% cetylpyridinium chloride (CPC) and found that perioperative self-care with CPC mouthwash may support antibiotic-induced changes in the oral flora. In this sub-analysis, we investigated how use of PVP-I and CPC products in the perioperative period affects postoperative systemic inflammation.

Methods

The subjects were 78 patients scheduled to undergo surgery under general anesthesia who received POM with random assignment of mouthwash containing PVP-I (n = 38) or CPC (n = 40). White blood cell (WBC) count, serum CRP level, and fever were used as postoperative inflammatory markers for comparison between the groups. Bacteria were collected from the dorsal surface of the tongue, and the total bacterial count, operational taxonomic unit (OTU) count, and Shannon Index were analyzed.

Results

Perioperative inflammatory indices such as WBC, CRP, and body temperature were compared between groups, and only mean CRP was significantly lower in the CPC group than PVP-I group (7.0 (range: 0-19.2) mg/dL vs. 5.3 (range: 0.1–21.0) mg/dL). A significant difference was found in the CRP level between the two groups. The incidence of high CRP (≥ 5 mg/dL) was significantly lower in the CPC group (16/40, 40%) compared to the PVP-I group (24/38, 63.2%). In multivariate analysis, the intervention product was a significant independent factor related to high CRP. The lower CRP in the CPC group was associated with a lower OTU count and lower Shannon Index.

Conclusion

The results suggest that use of CPC in POM is associated with a lower CRP level. Use of mouthwash containing CPC may decrease bacterial diversity on the dorsal surface of the tongue, and this may reduce postoperative complications such as pneumonia.

Trial registration:

University Hospitals Medical Information Network Clinical Trials Registry (UMIN-CTR), UMIN000030919. Registered January 21, 2018.

Perioperative oral management

Cetylpyridinium Chloride

Povidone iodine

C-reactive protein

Shannon Index

Microbiota

Many reports have suggested that perioperative oral management (POM) can reduce postoperative surgical site infection (SSI), pneumonia, and other complications [1–3]. Poor oral hygiene and bacteria in dental plaque increase the risk of pneumonia as a perioperative complication [4–6], and the tongue coating can act as a reservoir of bacteria related to development of aspiration pneumonitis and perioperative pneumonia [7–10].

The safety and efficacy of cetylpyridinium chloride (CPC) as an oral hygiene product have been shown, and this product prevents dental plaque formation and gingivitis, as well as maintaining oral hygiene with a long-lasting effect as an antibacterial agent that is absorbed on the tooth surface [11–13]. We have previously performed a randomized controlled feasibility study to examine bacteriological and clinical differences between povidone iodine (PVP-I) and CPC, which is commonly used in POM in Japan [14]. The results showed that an antibiotic-induced decrease of Streptococcus could be maintained for one week after surgery in patients treated with CPC. Thus, use of CPC in the perioperative period may support changes in oral bacterial flora caused by antibiotics. There were also differences in changes of bacterial flora caused by PVP-I or CPC, but it was unclear how these differences affected postoperative complications. Therefore, in this study, we analyzed the relationship between inflammatory markers, as indicators of postoperative complications, and tongue coating bacteria after perioperative intervention with mouthwash containing PVP-I or CPC.

Study design and patient selection

This study was a sub-analysis of a randomized parallel-group feasibility clinical study performed at Shinshu University Hospital from April 2018 to September 2021. The study was approved by the ethical committee of our university (Approval no. 3925) and was conducted in accordance with the 1964 Declaration of Helsinki. The study design is described elsewhere [14]. A total of 100 patients who were scheduled to undergo surgery under general anesthesia were invited to participate in the study. The inclusion criteria for participant inclusion were as follows: (1) planned for surgery under general anesthesia at our hospital; (2) visited the oral care center before surgery; (3) no antibiotic therapy within the past week; (4) no neoadjuvant therapy, such as radiation therapy or chemotherapy of the head and neck region; (5) 10 or more residual teeth; (6) capable of 20-s gargling or mouthwash; (7) no use of any toothpaste during the study; and (8) capable of understanding an explanation given on an information sheet and providing written consent. The exclusion criteria were as follows: (1) planned surgery of the head and neck region; (2) postoperative need for artificial ventilation; (3) allergy to CPC or PVP-I products; (4) diabetes; (5) likely to be transferred to another hospital or die immediately after surgery; and (6) considered unsuitable for the study by the investigator.

Study intervention

The subjects were randomly divided into PVP-I (n = 49) and CPC (n = 51) groups. Assignment was performed by Electronic Data Capture with the Alliance Clinical Research Support System. On the day before surgery, patients received a clinical evaluation and professional oral care (POC) (scaling and professional mechanical tooth cleaning) and were instructed to use 0.05% CPC mouthwash (Sunstar. Inc) or 7% PVP-I gargle (Nichi-Iko Pharmaceutical Co., Ltd.) diluted 15- to 30-fold (approximately 0.23–0.47%) after brushing before surgery and for one week after surgery.

Data collection

On the day before surgery, all subjects were examined for baseline characteristics and clinical indicators by a dentist or dental hygienist and underwent the same procedures of sample collection and POC comprising scaling and professional mechanical tooth cleaning. The oral hygiene index (OHI-S) score [15] was assessed before surgery and one week after surgery. White blood cell (WBC) count, serum C-reactive protein (CRP) level, and body temperature were examined as markers of postoperative systemic inflammation. Measurements were taken at several time points in the first week after surgery, and the highest value was considered to be representative. Tongue coating was sampled by wiping the mucosa on the right and left sides twice each with BD BBL Culture Swab TM EZ (Becton, Dickinson and Company) immediately before oral intubation at surgery. The analysis of tongue coating was based on 16S rRNA gene sequencing and the total bacteria counts were measured by a quantitative polymerase chain reaction (qPCR) assay, as described previously [14]. The resulting 16S sequences were clustered at 97% homology to identify operational taxonomic units (OTU). The OTU count indicates bacterial richness; that is, an ecosystem with many different species. The Shannon index, an indicator in 16S rRNA gene analysis, was evaluated to determine the richness and evenness of the bacterial community [16, 17]. Past reports suggest that oral care is insufficient when these indexes are high [18].

Statistical analysis

Differences between groups were evaluated by Student t-test for data following a normal distribution and by Mann-Whitney U test for other data. A chi-square test was used to test for significant differences in categorical variables. All statistical analyses were performed using SPSS ver. 28.0.1.1 (IBM Corp.) and R ver. 4.4, with significance defined as p < 0.05. The highest WBC, CRP, and body temperature in one week after surgery were compared between the groups. Multiple logistic regression analysis was used with dependent variables selected based on the hypothesis of the study and the results of comparisons between the groups. The objective factors were WBC, CRP, or body temperature and the candidate explanatory factors were age, gender, smoking habit, OHI-S, surgical site, surgical time, period of administration of antibiotics, types of antibiotics, and intervention product. To avoid bias and inaccurate model fitting, explanatory variables in the analysis were implemented with the number of categories set at about one-tenth of the dependent variables [19]. Regarding model goodness of fit, a Hosmer-Lemeshow test was performed, and the correct discriminant rate was confirmed.

Characteristics of the subjects

Of the 100 subjects registered in the study, 83 (41 PVP-I, 42 CPC) were included in the analysis, while 9 PVP-I and 8 CPC subjects were excluded based on the inclusion and exclusion criteria. In this sub-analysis, 38 PVP-I and 40 CPC subjects were analyzed, after excluding 5 subjects due to loss of data for CRP. The characteristics of the subjects are shown in Table 1. There were no significant differences between the groups.

Table 1

Characteristics of the subjects
Variable	PVP-I group (n = 38)	CPC group (n = 40)	p-value
Age (years) ^a	64.0 ± 15.0	66.1 ± 10.6	0.311
Gender (male/female) ^b	20/18	27/13	0.099
Smoking habit (yes/no) ^b	10/28	16/24	0.200
OHI-S ^c	1.0 (0–4.0)	1.6 (0-4.5)	0.192
Surgical site (Respiratory organs/Digestive organs/Hepatobiliary and pancreatic/Urinary organs/Gynecologic organs/Orthopedic) ^b	7/17/6/2/1/5	8/12/10/6/0/4	0.417
Surgical time (min) ^c	241.5 (63–834)	228.5 (48–810)	0.675
Period of administration of antibiotics (days) ^c	2.5 (1–7)	2.0 (1–7)	0.188
Types of antibiotics (1st generation cephem/2nd generation cephem/others) ^b	19/16/3	24/11/4	0.441
P-values are for between-group comparison for each variable. Differences were considered significant at P < 0.05. ^a Mean ± standard deviation, t-test; ^b number, chi-square test; ^c median (range), Mann-Whitney U test.

Postoperative inflammation indices in the PVP-I and CPC groups

The mean WBC and body temperature were 9,652 (range: 1,460 − 17,300) cells/µL and 37.6°C (36.5–39.2°C) in the PVP-I group, and 9,089 (1,160 − 17,500) cells/µL and 37.4°C (36.5–38.8°C) in the CPC group, with no significant differences between the groups. However, the mean CRP level was significantly lower in the CPC group compared to the PVP-I group (7.0 (0-19.2) vs. 5.3 (0.1–21.0) mg/dL) (Fig. 1).

Multivariate analysis of factors contributing to high CRP

To identify factors associated with higher CRP, CRP was defined as high (≥ 5 mg/dL) or low (< 5 mg/dL) based on use of this cut-off in many previous studies [20–25]. Univariate analysis performed for nine variables (Table 2) showed that smoking habit (p = 0.200), surgical site (p = 0.004), surgical time (p = 0.005), and intervention product (p = 0.041) were related to the serum CRP level at p ≤ 0.200. In multiple logistic regression analysis with these 4 factors as explanatory variables, the intervention product (odds ratio: 0.30; 95% confidence interval: 0.10–0.94; p = 0.034) was a significant independent factor. A model chi-square test gave p < 0.05, a Hosmer-Lemeshow test gave p = 0.894, and the percentage correct classification was 71.8%.

Table 2

Multiple logistic regression analysis for CRP
Variable	CRP ≥ 5 mg/mL (n = 40)	CRP < 5 mg/mL (n = 38)	Univariate analysis p-value	Multivariate analysis p-value
Age (years)	65.0 ± 12.6	65.1 ± 13.3	0.885 ^a
gender (male/female)	25/15	22/16	0.678 ^b
Smoking habit (yes/no)	16/24	10/28	0.200 ^b	0.118
OHI-S	1.6 (0-4.5)	1.4 (0–4)	0.270 ^c
Surgical site (Respiratory organs/Digestive organs/Hepatobiliary and pancreatic/Urinary organs/Gynecologic organs/Orthopedic)	7/20/10/2/1/0	8/9/6/6/0/9	0.004 ^b	0.423
Surgical time (min)	327.5 (87–834)	239.4 (48–810)	0.005 ^c	0.770
Period of administration of antibiotics (days)	2.5 (1–7)	2.6 (1–6)	0.458 ^c
Types of antibiotics (1st generation cephem/2nd generation cephem/others)	19/17/3	24/10/4	0.283 ^b
Intervention product (PVP-I/CPC)	24/16	14/24	0.041 ^b	0.034
P-values for between-group comparison for each variable. Differences were considered significant at P < 0.05. ^a Mean ± standard deviation, t-test; ^b number, chi-square test; ^c median (range), Mann-Whitney U test.

Relationship of tongue coating bacteria before surgery with postoperative CRP

Total bacterial count, OTU count, and Shannon Index in tongue coating immediately before surgery were compared in subjects with high and low CRP (Fig. 2). The Shannon Index was significantly lower in those with low CRP. To compare the effects of the different mouthwash products, the markers in tongue coating immediately before surgery were compared in subjects with high and low CRP in the PVP-I and CPC groups (Fig. 3). The total bacteria counts did not differ significantly between subjects with high and low CRP in either group, but the OTU count and Shannon Index in subjects with high CRP were significantly higher than in those with low CRP in the CPC group (Fig. 3).

There are many useful aspects of oral care in the perioperative period, including a decrease of complications of infections and postoperative pneumonia, and shortening of the period of hospitalization [1–3, 26–28]. Thus, oral hygiene, including decontamination and mechanical cleaning of the oral cavity by dental professionals, has profound clinical significance, including reduced rates of pneumonia and reduced mortality from respiratory diseases. Studies of oral colonization by pneumonia-related pathogens have also found a positive effect of oral care on eliminating pathogens [29].

Chlorhexidine hydrochloride (CHX) is commonly used as antiseptic mouthwash in oral care management, but use of CHX in Japan is restricted due to allergy concerns. Instead, PVP-I and CPC are commonly used as alternatives to CHX in oral care management. Thus, we performed a randomized controlled feasibility study of CPC and PVP-I products for better selection of a perioperative oral care product in Japan. In this previous study, we compared changes in bacteria counts and bacterial flora after use of PVP-I and CPC in POM [14]. CPC was found to maintain an antibiotic-mediated decrease of Streptococcus, which is related to postoperative pneumonia, from day 1 until a week after surgery. This result suggested that CPC might support the antibacterial effects of antibiotics in the perioperative period.

The current study was performed to evaluate the impact of perioperative use of self-care products on systemic inflammation. Postoperative inflammatory reactions are caused by surgery itself, as well as complications such as SSI, pneumonia, urinary tract infection, and other bacterial infections. We aimed to evaluate the incidence of SSI or pneumonia as a primary endpoint, but the postoperative rate of SSIs is only about 5% and that of pneumonia is 0.5–28% [30]. The relatively low occurrence of these events makes it challenging to collect sufficient cases in an intervention study. Therefore, we analyzed the effect of use of PVP-I and CPC in the perioperative period using inflammatory markers (WBC, CRP, body temperature) as surrogates in this sub-analysis. No significant differences were detected in body temperature and WBC, but there was a significant difference in CRP depending on the intervention product (Fig. 1). Based on these results, we decided to use CRP as an indicator in the analysis. CRP is a protein that appears in blood several hours after cellular destruction in tissues caused by infection or inflammatory disease, and is particularly useful as an inflammatory marker of disease status and for detection of postoperative infection [31–33].

Univariate analysis with nine variables (Table 2) was performed to compare cases with high CRP (≥ 5 mg/dL) and low CRP (< 5 mg/dL). Multivariate logistic regression analysis indicated that the mouthwash product was significantly associated (odds ratio: 0.30) with high CRP. These data are related to the usefulness of CPC, as suggested in our previous report [14]. POM may affect the CRP level [34], but POM was provided to both groups in the current study, with no group without oral care. Thus, it is unlikely that POM influenced the comparison of CRP between the PVP-I and CPC groups, which supports the conclusion that CPC used in support of oral care has a beneficial effect on CRP.

The relationship of CRP with Shannon Index and OTU count in tongue coating before surgery (upon intubation) was also analyzed. Postoperative pneumonia is a common complication associated with changes of bacteria in the oral cavity. This condition is most commonly caused by bacteria in the oropharyngeal region that invade the respiratory tract during the perioperative period. Therefore, we focused on bacteria on the dorsal surface of the tongue, which acts as a large reservoir of oropharyngeal bacteria. The Shannon Index and OTU count in tongue coating measured immediately before surgery (upon administration of preoperative antibiotics and intubation) reflect the oral environment influenced by preoperative POC and self-care with individual products. The Shannon Index in tongue coating immediately before surgery was significantly lower in cases with low CRP (< 5 mg/dL) compared to those with high CRP (≥ 5 mg/dL). Furthermore, patients who received POM with CPC and had low CRP (< 5 mg/dL) had a significantly lower OTU count and Shannon Index in tongue coating immediately before surgery. These findings suggest that oral cleanliness before surgery may be related to prevention of postoperative inflammation.

This study used inflammatory markers as a surrogate for postoperative complications due to the small number of cases. Since high CRP implies a normal postoperative response and degree of invasiveness, in addition to complications, we cannot conclude that use of CPC actually results in fewer postoperative complications. However, the significant reduction of CRP with use of CPC, which can control the bacterial flora, is noteworthy and suggests the need for a further study with more cases to clarify the effect of CPC and the association between mouthwash and perioperative complications. In addition, perioperative oral care is usually a combination of several oral cleaning procedures, including use of tooth or tongue brushes and oral moisturizers, and we could not verify which oral care combination is best to prevent postoperative complications. Thus, the preventive effect of the combination of physical cleaning tools such as tongue brushes and antimicrobial agents should also be investigated as an important direction for future research.

The results of the study showed that use of CPC as an antiseptic mouthwash in POM for perioperative patients has a significant positive effect on systemic inflammation (CRP level) and on the richness and evenness of the bacterial community (Shannon Index) on the surface of the tongue. CPC seems to be useful for reducing excessive postoperative inflammation by promoting oral hygiene in the mouth cavity.

CHX

Chlorhexidine hydrochloride

CPC

Cetylpyridinium chloride

CRP

C-reactive protein

OTU

Operational taxonomic unit

OHI-S

Oral Health Information Suite

POM

Perioperative oral management

POC

professional oral care

PVP-I

Povidone iodine

qPCR

quantitative polymerase chain reaction

SSI

Surgical site infection

WBC

White blood cell

Ethics approval and consent to participate

The study was approved by Shinshu University Certified Review Board of Clinical Research (Approval no. 3925) and was conducted in accordance with the 1964 Declaration of Helsinki. Subjects read an explanation of the study on an information sheet and provided written consent.

Consent for publication

Not applicable

Availability of data and materials

The datasets generated and analyzed during the current study are available in the DDBJ Sequenced Read Archive repository [accession numbers DRA013196 and DRA013197].

Competing interests

Haruko Tobata and Kota Yanai are employees of Sunstar Inc, which developed the CPC mouthwash used in the study. All other authors have no conflicts of interest.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors' contributions

JK contributed to conception and design, data acquisition and interpretation, and drafted and critically revised the manuscript. HO and HK contributed to conception and design, data interpretation, and critically revised the manuscript. KY and HT contributed to manuscript drafting and data analysis, and interpretation, and drafted the manuscript. HS contributed to data acquisition and critically revised the manuscript. All authors approved the final version of the manuscript.

Acknowledgements

The authors thank the staff of the participating study centers for their support.

Authors' information

Not applicable

Hiramatsu T, Sugiyama M, Kuwabara S, Tachimori Y, Nishioka M. Effectiveness of an outpatient preoperative care bundle in preventing postoperative pneumonia among esophageal cancer patients. Am J Infect Control. 2014;42:385–8. https://doi.org/10.1016/j.ajic.2013.11.017.
Soutome S, Yanamoto S, Funahara M, Hasegawa T, Komori T, Yamada S, et al. Effect of perioperative oral care on prevention of postoperative pneumonia associated with esophageal cancer surgery: A multicenter case-control study with propensity score matching analysis. Medicine. 2017;96:e7436. http://dx.doi.org/10.1097/MD.0000000000007436.
Iwata E, Hasegawa T, Yamada S, Kawashita Y, Yoshimatsu M, Mizutani T, et al. Effects of perioperative oral care on prevention of postoperative pneumonia after lung resection: Multicenter retrospective study with propensity score matching analysis. Surgery. 2019;165:1003–7. https://doi.org/10.1016/j.surg.2018.11.020.
Akutsu Y, Matsubara H, Okazumi S, Shimada H, Shuto K, Shiratori T, et al. Impact of preoperative dental plaque culture for predicting postoperative pneumonia in esophageal cancer patients. Surgery. 2008;25:93–7. https://doi.org/10.1159/000121903.
Nomura Y, Inai Y, Shimpo Y, Okada A, Yamamoto Y, Sogabe K, et al. Incidence of postoperative pneumonia and oral microbiome for patients with cancer operation. Appl Sci. 2022;12:2920. https://doi.org/10.3390/app12062920.
Akutsu Y, Matsubara H, Shuto K, Shiratori T, Uesato M, Miyazawa Y, et al. Pre-operative dental brushing can reduce the risk of postoperative pneumonia in esophageal cancer patients. Surgery. 2010;147:497–502. https://doi.org/10.1016/j.surg.2009.10.048.
Abe S, Ishihara K, Adachi M, Okuda K. Tongue-coating as risk indicator for aspiration pneumonia in edentate elderly. Arch Gerontol Geriatr. 2008;47:267–75. https://doi.org/10.1016/j.archger.2007.08.005.
Takeshita T, Tomioka M, Shimazaki Y, Matsuyama M, Koyano K, Matsuda K, et al. Microfloral characterization of the tongue coating and associated risk for pneumonia-related health problems in institutionalized older adults. J Am Geriatr Soc. 2010;58:1050–7. https://doi.org/10.1111/j.1532-5415.2010.02867.x.
Funahara M, Soutome S, Hayashida S, Umeda M. An analysis of the factors affecting the number of bacteria in the saliva of elderly adults in need of care. Int J Gerontol. 2018;12:205–7. https://doi.org/10.1016/j.ijge.2018.01.003.
Funahara M, Yanamoto S, Soutome S, Hayashida S, Umeda M. Clinical observation of tongue coating of perioperative patients: factors related to the number of bacteria on the tongue before and after surgery. BMC Oral Health. 2018;18:223. https://doi.org/10.1186/s12903-018-0689-x.
Pitten FA, Kramer A. Efficacy of cetylpyridinium chloride used as oropharyngeal antiseptic. Arzneimittelforschung. 2001;51:588–95. https://doi.org/10.1055/s-0031-1300084.
Haps S, Slot DE, Berchier CE, Van der Weijden GA. The effect of cetylpyridinium chloride-containing mouth rinses as adjuncts to toothbrushing on plaque and parameters of gingival inflammation: a systematic review. Int J Dent Hyg. 2008;6:290–303. https://doi.org/10.1111/j.1601-5037.2008.00344.x.
Sreenivasan PK, Haraszyhy VI, Zambon JJ. Antimicrobial efficacy of 0.05% cetylpyridinium chloride mouth rinses. Lett Appl Microbiol. 2012;56:14–20. https://doi.org/10.1111/lam.12008.
Otagiri H, Kurita H, Yamada S, Sakai H, Tobata H, Yanai K, et al. Efficacy of cetylpridium chloride mouthwash compared to povidone iodine on oral flora for perioperative patient care: A randomized controlled feasibility study. J Oral Maxillofac Surg Med Pathol. 2023;473–9. https://doi.org/10.1016/j.ajoms.2023.02.009.
Greene JG, Vermillion JR. The simplified oral hygiene index. J Am Dent Assoc. 1964;68:7–13. https://doi.org/10.14219/jada.archive.1964.0034.
Pereira JV, Leomil L, Rodrigues-Albuquerque F, Pereira JO, Astolfi-Filho S. Bacterial diversity in the saliva of patients with different oral hygiene indexes. Braz Dent J. 2012;23:409–16. https://doi.org/10.1590/S0103-64402012000400017.
Takeshita T, Kageyama S, Furuta M, Tsuboi H, Takeuchi K, Shibata Y, et al. Bacterial diversity in saliva and oral health-related conditions: the Hisayama Study. Sci Rep. 2016;6:22164. https://doi.org/10.1038/srep22164.
Bertelsen RJ, Barrionuevo AMP, Shigdel R, Lie SA, Lin H, Real FG, et al. Association of oral bacteria with oral hygiene habits and self-reported gingival bleeding. J Clin Periodontol. 2022;49:768–81. 10.1111/jcpe.13644. https://onlinelibrary.wiley.com/doi/.
Peduzzi P, Concato J, Kemper E, Holford TR, Feinstein AR. A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol. 1996;49:1373–9. https://doi.org/10.1016/S0895-4356(96)00236-3.
Nunes BK, Lacerda RA, Jardim JM. Revisão sistemática e metanálise sobre o valor preditivo da proteína C-reativa em infecção pós-operatória [Systematic review and meta-analysis of the predictive value of C-reactive protein in postoperative infections]. Rev Esc Enferm USP. 2011;45:1488–94. https://doi.org/10.1590/S0080-62342011000600030.
Vandijck DM, Hoste EA, Blot SI, Depuydt PO, Peleman RA, Decruyenaere JM. Dynamics of C-reactive protein and white blood cell count in critically ill patients with nosocomial Gram positive vs. Gram negative bacteremia: a historical cohort study. BMC Infect Dis. 2007;7:106. https://doi.org/10.1186/1471-2334-7-106 .
Rogowski O, Rotstein R, Zeltzer D, Misgav S, Justo D, Avitzour D, et al. Superiority of a functional leukocyte adhesiveness/aggregation test over the white blood cell count to discriminate between mild and significant inflammatory response in patients with acute bacterial infections. J Clin Lab Anal. 2002;16:187–93. https://doi.org/10.1002/jcla.10041.
Lelubre C, Anselin S, Zouaoui Boudjeltia K, Biston P, Piagnerelli M. Interpretation of C-reactive protein concentrations in critically ill patients. Biomed Res Int. 2013:1–11. https://doi.org/10.1155/2013/124021
Pih GY, Na HK, Ahn JY, Jung KW, Kim DH, Lee JH, et al. Risk factors for complications and mortality of percutaneous endoscopic gastrostomy insertion. BMC Gastroenterol. 2018;18:101. https://doi.org/10.1186/s12876-018-0825-8.
Zawiślak E, Nowak R. Odontogenic head and neck region infections requiring hospitalization: An 18-month retrospective analysis. Biomed Res Int. 2021;1–8. https://doi.org/10.1155/2021/7086763.
Ishikawa A, Yoneyama T, Hirota K, Miyake Y, Miyatake K. Professional oral health care reduces the number of oropharyngeal bacteria. J Dent Res. 2008;87:594–8. https://doi.org/10.1177/154405910808700602.
Han YW, Wang X. Mobile microbiome: oral bacteria in extra-oral infections and inflammation. J Dent Res. 2013;92:485–91. https://doi.org/10.1177/0022034513487559.
Wade WG. The oral microbiome in health and disease. Pharmacol Res. 2013;69:137–43. https://doi.org/10.1016/j.phrs.2012.11.006.
Akio T, Hiroko M. Prevention of aspiration pneumonia(AP)with oral care. Arch Gerontol Geriatr. 2012;55:16–21. https://doi.org/10.1016/j.archger.2011.06.029.
Morad C, Chukwuweike U. The epidemiology and risk factors for postoperative pneumonia. J Clin Med Res. 2017;9:466–75. https://www.jocmr.org/index.php/JOCMR/article/view/3002/1808.
Iizuka T, Lindqvist C. Changes in C-reactive protein associated with surgical treatment of mandibular fractures. J Oral Maxillofac Surg. 1991;49:464–7. https://doi.org/10.1016/0278-2391(91)90168-L.
Mustard RA Jr, Bohnen JM, Haseeb S, Kasina R. C-reactive protein levels predict postoperative septic complications. Arch Surg. 1987;122:69–73. https://doi:10.1001/archsurg.1987.01400130075011.
Aono H, Ohwada T, Kaneko N, Fuji T, Iwasaki M. The post-operative changes in the level of inflammatory markers after posterior lumbar interbody fusion. J Bone Joint Surg Br. 2007;89:1478–81. https://doi.org/10.1302/0301-620X.89B11.19478.
Shigeishi H, Ohta K, Fujimoto S. Preoperative oral health care reduces postoperative inflammation and complications in oral cancer patients. Exp Ther Med. 2016;12:1922–8. https://doi.org/10.3892/etm.2016.3532.

No competing interests reported.

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You are reading this latest preprint version

Effects of differences in perioperative mouthwash on oral bacteria and postoperative complications: Sub-analysis of a mouthwash intervention study

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Version 1

Abstract

Background

Methods

Results

Conclusion

Trial registration:

Figures

Background

Materials and Methods

Study design and patient selection

Study intervention

Data collection

Statistical analysis

Results

Characteristics of the subjects

Postoperative inflammation indices in the PVP-I and CPC groups

Multivariate analysis of factors contributing to high CRP

Relationship of tongue coating bacteria before surgery with postoperative CRP

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1