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Correspondence |

Assess Dental Plaque and Suction-Extricated Bacteria Adequately FREE TO VIEW

Hiromitsu Kishimoto, DDS, PhD; Masahiro Urade, DDS, PhD
Author and Funding Information

From the Department of Oral and Maxillofacial Surgery, Hyogo College of Medicine.

Correspondence to: Hiromitsu Kishimoto, DDS, PhD, Department of Oral and Maxillofacial Surgery, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, Hyogo 663-8501, Japan; e-mail: kisihiro@hyo-med.ac.jp


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(2):500. doi:10.1378/chest.09-1686
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To the Editor:

We read with great interest the recent article in CHEST (August 2009) by Pobo et al1 concerning dental brushing for preventing ventilator-associated pneumonia (VAP). Since dental plaque can serve as a bacterial reservoir2 that may cause VAP, oral care regimens that remove dental plaque could reduce the incidence of VAP.3 Toothbrushes are generally regarded as the best tools for plaque removal. For example, Fields reported they could drop the VAP rate close to zero by toothbrushing intubated patients every 8 h.4 However, the study by Pobo et al1 did not demonstrate the effectiveness of electric toothbrushing in addition to standard oral care for the prevention of VAP.

At this stage, we should not conclude that toothbrushing is not necessarily required in oral care for VAP prevention. We would indicate three problems in this study. First, neither dental plaque nor microbial flora was examined between the two groups. As the effectiveness of toothbrushing depends on using toothbrushes in a proper fashion, deposition of dental plaque should be quantified. Second, care regimens in the intervention (toothbrush) group seems to be inadequate. The control group was subjected to a standard oral care regimen where a gauze containing 0.12% chlorhexidine digluconate was applied to teeth, tongue, and mucosal surfaces. Then, 10 mL of chlorhexidine digluconate was injected into the oral cavity, which was then aspirated after 30 s. Besides the intervention described for the control group, toothbrushing was performed, and finally the tongue was also brushed. If the oral care is performed in the author’s order, there is no suction after brushing the teeth and tongue. Therefore, to collect extricated bacteria originally contained in dental plaque by toothbrushing, deep oropharyngeal suctioning after toothbrushing is also essential. Moreover, the incidence of VAP exceeds 20% of the study population, which is high compared to other studies.4,5 It seems that this number is disputable if the VAP bundle is properly practiced, which should include oral care. Third, in the “Discussion” section the authors stated that a lack of compliance with measures preventing VAP was not checked in their study.1 For these reasons, we expect new trials to be performed under new, precise protocols that should confirm the removal of dental plaque after toothbrushing and the suction of extricated bacteria from the teeth or tongue.

Pobo A, Lisboa T, Rodriguez A, et al. A randomized trial of dental brushing for preventing ventilator-associated pneumonia. Chest. 2009;1362:433-439. [CrossRef] [PubMed]
 
Scannapieco FA. Role of oral bacteria in respiratory infection. J Periodontol. 1999;707:793-802. [CrossRef] [PubMed]
 
Munro CL, Grap MJ. Oral health and care in the intensive care unit: state of the science. Am J Crit Care. 2004;131:25-33. [PubMed]
 
Fields LB. Oral care intervention to reduce incidence of ventilator-associated pneumonia in the neurologic intensive care unit. J Neurosci Nurs. 2008;405:291-298. [CrossRef] [PubMed]
 
Youngquist P, Carroll M, Farber M, et al. Implementing a ventilator bundle in a community hospital. Jt Comm J Qual Patient Saf. 2007;334:219-225. [PubMed]
 

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References

Pobo A, Lisboa T, Rodriguez A, et al. A randomized trial of dental brushing for preventing ventilator-associated pneumonia. Chest. 2009;1362:433-439. [CrossRef] [PubMed]
 
Scannapieco FA. Role of oral bacteria in respiratory infection. J Periodontol. 1999;707:793-802. [CrossRef] [PubMed]
 
Munro CL, Grap MJ. Oral health and care in the intensive care unit: state of the science. Am J Crit Care. 2004;131:25-33. [PubMed]
 
Fields LB. Oral care intervention to reduce incidence of ventilator-associated pneumonia in the neurologic intensive care unit. J Neurosci Nurs. 2008;405:291-298. [CrossRef] [PubMed]
 
Youngquist P, Carroll M, Farber M, et al. Implementing a ventilator bundle in a community hospital. Jt Comm J Qual Patient Saf. 2007;334:219-225. [PubMed]
 
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