Assess dental plaque and suction-extricated bacteria adequately.

We read with great interest the recent article in CHEST (August 2009) by Pobo et al 1 concerning dental brushing for preventing ventilator-associated pneumonia (VAP). Since dental plaque can serve as a bacterial reservoir 2 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 al 1 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 fl ora 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 quantifi ed. 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 fi nally 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 confi rm the removal of dental plaque after toothbrushing and the suction of extricated bacteria from the teeth or tongue.