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Tanmay S. Panchabhai, MBBS; Neha S. Dangayach, MBBS; Anand Krishnan, MD; Vatsal M. Kothari, MD, MRCP; Dilip R. Karnad, MD
Author and Funding Information

From the Medical-Neuro Intensive Care Unit, Department of Medicine, Seth GS Medical College and KEM Hospital.

Correspondence to: Dilip R. Karnad, MD, Professor of Medicine, Seth GS Medical College and KEM Hospital, Mumbai: 400 012, India; e-mail: drkarnad@rediffmail.com


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;137(1):238. doi:10.1378/chest.09-1834
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To the Editor:

We are grateful to Wise et al1 for their interest in our study recently published in CHEST (May 2009).2 We offer the following responses: Colonization of the dental plaque and oral mucosa has consistently been shown to be a reservoir for nosocomial pneumonia. An earlier investigation by Fourrier et al3 showed that decontamination with 0.2% chlorhexidine decreased the incidence of bacterial colonization of the dental plaque. The use of chlorhexidine oral rinse has also been shown to have a residual activity, preventing the accumulation of dental plaque even after 4 days of discontinuation of oral hygiene.4 In our study,2 all patients admitted to the ICU underwent oral cleansing within 6 h of admission. Hence, plaque formation and colonization should have been reduced as early as the first day in the ICU. Although the oral cleansing procedure in our study did not include brushing teeth, it included swabbing the oral, buccal, and posterior pharyngeal mucosa, which would possibly have an additional effect on a bacterial colonization of the pharynx.

Of the two studies in ICU patients using 2% chlorhexidine for oral cleansing, one did include toothbrushing as a part of oral cleansing protocol,5 although both studies showed statistically significant reduction in the incidence of nosocomial pneumonia.5,6 Hence, higher concentrations of chlorhexidine ( >2%) would still be an argument for the possible lack of benefit with 0.2% chlorhexidine in our study and an attractive option for oral cleansing in ICU patients.

Thus, although Wise et al1 may be correct in suggesting that on a theoretical basis mechanical oral cleansing with chlorhexidine accompanied by toothbrushing might be more beneficial in ICU patients, this needs to be proven in clinical studies. Early reports suggest that toothbrushing may carry an additional risk of bloodstream infections in ICU patients.7,8 A recent randomized trial comparing oral cleansing with 0.12% chlorhexidine with or without electrical toothbrushing failed to demonstrate significant difference.9

Hingston CD, Cole JM, Hingston EJ, Frost PJ, Wise MP. Oral hygiene and nosocomial pneumonia in critically ill patients. Chest. 2009;1371:237. [CrossRef]
 
Panchabhai TS, Dangayach NS, Krishnan A, Kothari VM, Karnad DR. Oropharyngeal cleansing with 0.2% chlorhexidine for prevention of nosocomial pneumonia in critically ill patients: an open-label randomized trial with 0.01% potassium permanganate as control. Chest. 2009;1355:1150-1156. [CrossRef] [PubMed]
 
Fourrier F, Cau-Pottier E, Boutigny H, Roussel-Delvallez M, Jourdain M, Chopin C. Effects of dental plaque antiseptic decontamination on bacterial colonization and nosocomial infections in critically ill patients. Intensive Care Med. 2000;269:1239-1247. [CrossRef] [PubMed]
 
Sekino S, Ramberg P, Uzel NG, Socransky S, Lindhe J. The effect of a chlorhexidine regimen on de novo plaque formation. J Clin Periodontol. 2004;318:609-614. [CrossRef] [PubMed]
 
Tantipong H, Morkchareonpong C, Jaiyindee S, Thamlikitkul V. Randomized controlled trial and meta-analysis of oral decontamination with 2% chlorhexidine solution for the prevention of ventilator-associated pneumonia. Infect Control Hosp Epidemiol. 2008;292:131-136. [CrossRef] [PubMed]
 
Koeman M, van der Ven AJ, Hak E, et al. Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia. Am J Respir Crit Care Med. 2006;17312:1348-1355. [CrossRef] [PubMed]
 
Lucas VS, Gafan G, Dewhurst S, Roberts GJ. Prevalence, intensity and nature of bacteraemia after toothbrushing. J Dent. 2008;367:481-487. [CrossRef] [PubMed]
 
Jones DJ, Munro CL. Oral care and the risk of bloodstream infections in mechanically ventilated adults: a review. Intensive Crit Care Nurs. 2008;243:152-161. [CrossRef] [PubMed]
 
Pobo A, Lisboa T, Rodriguez A, et al. RASPALL Study Investigators A randomized trial of dental brushing for preventing ventilator-associated pneumonia. Chest. 2009;1362:433-439. [CrossRef] [PubMed]
 

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References

Hingston CD, Cole JM, Hingston EJ, Frost PJ, Wise MP. Oral hygiene and nosocomial pneumonia in critically ill patients. Chest. 2009;1371:237. [CrossRef]
 
Panchabhai TS, Dangayach NS, Krishnan A, Kothari VM, Karnad DR. Oropharyngeal cleansing with 0.2% chlorhexidine for prevention of nosocomial pneumonia in critically ill patients: an open-label randomized trial with 0.01% potassium permanganate as control. Chest. 2009;1355:1150-1156. [CrossRef] [PubMed]
 
Fourrier F, Cau-Pottier E, Boutigny H, Roussel-Delvallez M, Jourdain M, Chopin C. Effects of dental plaque antiseptic decontamination on bacterial colonization and nosocomial infections in critically ill patients. Intensive Care Med. 2000;269:1239-1247. [CrossRef] [PubMed]
 
Sekino S, Ramberg P, Uzel NG, Socransky S, Lindhe J. The effect of a chlorhexidine regimen on de novo plaque formation. J Clin Periodontol. 2004;318:609-614. [CrossRef] [PubMed]
 
Tantipong H, Morkchareonpong C, Jaiyindee S, Thamlikitkul V. Randomized controlled trial and meta-analysis of oral decontamination with 2% chlorhexidine solution for the prevention of ventilator-associated pneumonia. Infect Control Hosp Epidemiol. 2008;292:131-136. [CrossRef] [PubMed]
 
Koeman M, van der Ven AJ, Hak E, et al. Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia. Am J Respir Crit Care Med. 2006;17312:1348-1355. [CrossRef] [PubMed]
 
Lucas VS, Gafan G, Dewhurst S, Roberts GJ. Prevalence, intensity and nature of bacteraemia after toothbrushing. J Dent. 2008;367:481-487. [CrossRef] [PubMed]
 
Jones DJ, Munro CL. Oral care and the risk of bloodstream infections in mechanically ventilated adults: a review. Intensive Crit Care Nurs. 2008;243:152-161. [CrossRef] [PubMed]
 
Pobo A, Lisboa T, Rodriguez A, et al. RASPALL Study Investigators A randomized trial of dental brushing for preventing ventilator-associated pneumonia. Chest. 2009;1362:433-439. [CrossRef] [PubMed]
 
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