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Angel Pobo, MD; Thiago Lisboa, MD; Ramiro Sole, MD; Jordi Rello, MD, PhD
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From the Critical Care Department (Drs Pobo, Lisboa, and Rello), Joan XXIII University Hospital, University Rovira i Virgili, Institut Pere Virgili (IISPV), CIBER Enfermedades Respiratorias (CIBERes); and the Dentistry Care Department (Dr Sole), Joan XXIII University Hospital, University Rovira I Virgili.

Correspondence to: Jordi Rello, MD, PhD, Critical Care Department, Joan XXIII University Hospital, Carrer Dr. Mallafre Guasch 4. (43007) Tarragona, Spain; e-mail: jrello.hj23.ics@gencat.cat


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):500-501. doi:10.1378/chest.09-2516
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To the Editor:

We thank Dr Kishimoto et al for their interest in our recent article in CHEST (August 2009)1 regarding dental brushing for preventing ventilator-associated pneumonia (VAP). To our knowledge, this is the first study to evaluate the contribution of an intensive oral hygiene protocol using electric toothbrushing to prevent VAP. Our findings suggest that the addition of a mechanical system with electric toothbrushing to standard oral care with chlorhexidine was not effective in preventing VAP. To the best of our knowledge, no universal recommendation regarding the best way to perform oral care in critically ill patients is available. Therefore, we designed an oral care strategy that includes a multidisciplinary approach (including nurses and an oral care expert), and, after a training period for several intensive care nurses, we started performing the technique described in our article. We appreciate Kishimoto et al’s opinion that in the intervention group (0.12% chlorhexidine digluconate every 8 h, plus tooth and tongue brushing every 8 h), after brushing, deep oropharyngeal suction could be done to remove extricated bacteria. We did not do this; instead, we performed an aspiration of the oral cavity. Munro et al2 used a strategy similar to that performed in our study, with similar results. Whether deep oropharyngeal suction after toothbrushing improves our ability to clean up the oral cavity and further reduces the risk of aspiration should be further documented in prospective studies.

We agree that dental plaque and microbial flora are important issues. We assessed the dental plaque and microbial flora from oropharynx quantitatively and qualitatively by collecting oral and pharyngeal swabs of each patient and doing a daily measure of the plaque index score.3 These data will be analyzed in an ongoing substudy.

Finally, we also expect to carry out further studies assessing the effect of toothbrushing on dental plaque colonization and to compare different techniques for oral hygiene performance. It would help us to design the optimal strategy for oral care and its role in VAP prevention.

Pobo A, Lisboa T, Rodriguez A, et al; RASPALL Study Investigators RASPALL Study Investigators A randomized trial of dental brushing for preventing ventilator-associated pneumonia. Chest. 2009;1362:433-439. [CrossRef] [PubMed]
 
Munro CL, Grap MJ, Jones DJ, McClish DK, Sessler CN. Chlorhexidine, toothbrushing, and preventing ventilator-associated pneumonia in critically ill adults. Am J Crit Care. 2009;185:428-437. [CrossRef] [PubMed]
 
Silness J, Löe H. Periodontal disease in pregnancy. 3. Response to local treatment. Acta Odontol Scand. 1966;246:747-759. [CrossRef] [PubMed]
 

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Pobo A, Lisboa T, Rodriguez A, et al; RASPALL Study Investigators RASPALL Study Investigators A randomized trial of dental brushing for preventing ventilator-associated pneumonia. Chest. 2009;1362:433-439. [CrossRef] [PubMed]
 
Munro CL, Grap MJ, Jones DJ, McClish DK, Sessler CN. Chlorhexidine, toothbrushing, and preventing ventilator-associated pneumonia in critically ill adults. Am J Crit Care. 2009;185:428-437. [CrossRef] [PubMed]
 
Silness J, Löe H. Periodontal disease in pregnancy. 3. Response to local treatment. Acta Odontol Scand. 1966;246:747-759. [CrossRef] [PubMed]
 
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