© 2007 American Thoracic Society
Mechanical Tooth Cleaning before Chlorhexidine ApplicationTo the Editor:We read with great interest the recent article by Koeman and coworkers (1). The authors showed that oropharyngeal decontamination with either chlorhexidine (CHX) or CHX/colistin reduced the development of ventilator-associated pneumonia (VAP). As colistin can be used intravenously for treatment of severe infections, its attractiveness as a prophylactic agent might be reduced. Therefore, more effective use of CHX alone should be discussed. Dental plaque can be a major reservoir of infection by respiratory pathogens in ICU patients (2). In general, chemical (pharmacological) plaque control such as an oral rinse with CHX is applicable easily and shows high compliance. However, the effect of chemical approaches against accumulated plaque is marginal, because plaque has the properties of a "biofilm" in which bacteria are considerably less sensitive to antimicrobial treatments than free-living planktonic bacteria (3). Therefore, mechanical tooth cleaning, such as tooth brushing, may be a better means than a chemical approach to help reduce oral bacteria, and may be able to assist in the removal of all pathogens among plaque, including anaerobes and multi-drug–resistant bacterial pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas. The significance of anaerobes as causative bacteria of VAP remains controversial (4), but oral bacteria such as Porphyromonas gingivalis, one of causative "anaerobes" of periodontal disease, may have a potential role in respiratory infection (5). Mechanical reduction of organisms will enhance the effectiveness of CHX on the remaining and/or regrowing organisms. We recommend mechanical oral care interventions prior to CHX application for patients who are scheduled for surgery and admission to the ICU. Preoperative interventions include professional tooth cleaning (PTC) and scaling, tooth extraction, filling decayed cavities, or other treatments for improvement of oral conditions. The day before the operation, if possible, PTC should be performed again and confirmed to be supragingival plaque-free using disclosing agents to improve plaque-assessment accuracy. Although it may be impossible that patients receive tooth cleaning before intubation, since emergent intubation is common in many ICU situations, rigorous mechanical tooth cleaning by ICU nurses or a dental hygienist should be performed as early as possible. As tubes traversing the oral cavity that keep the mouth open may contribute to the accumulation of plaque, measures against dry mouth, such as moisturizing gel application to the mucous membranes, should also be considered. Additional research is needed to evaluate whether rigorous mechanical tooth cleaning before CHX application assists in VAP prevention among ICU patients.
Hyogo College of Medicine Nishinomiya, Japan FOOTNOTES Conflict of Interest Statement: Neither author has a financial relationship with a commercial entity that has an interest in the subject of this manuscript. REFERENCES
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