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Learn more about ventilator associated pneumonia (VAP)

How VAP develops

  Problems caused by VAP  


Ventilator associated pneumonia (VAP) causes prolonged intubation and extended stays in intensive care units (ICU) resulting in increases in associated costs. It can also be a significant cause of mortality in compromised patients. 1,2,3,4

Dental plaque is a biofilm made up from bacteria and their excretions. At home we are not concerned about it, as actions such as eating and speaking help remove this film. ICU patients are exposed to many different bacteria than what is found in our homes: MRSA, Acinetobacter, Klebsiella or other potentially lethal bacteria may colonize in the warm and humid oropharyngeal environment.

Dental plaque is mostly located on the gum line and in-between the teeth. Using gauze or a sponge will not remove these bacteria. A soft brush with slightly longer bristles is ideal to remove plaque from inter-dental spaces. Use the modified Bass brushing technique (see video) and don’t put any pressure on the gums. This will ensure proper removal of the plaque film. It is important to break up this film prior to applying antibacterial solutions, as bacteria inside the biofilm are protected.
  If plaque and bacteria are not removed, they will drain down to the ET tube cuff. Since the cuff seal is never 100%, aspiration pneumonia can occur and VAP will develop. It is important as part of the oral care protocol to suction out the space above the cuff regularly in order to avoid aspiration of bacteria into the lungs.

VAP develops in 9-25% of all patients in ICU. Each case of VAP may cost the hospital as much as $30,000-$40,000. It is therefore in the best interest of each hospital to reduce their VAP rates and associated costs.
VAP is also one of the highest causes for morbidity and mortality in ICU, with mortality rates as high as 10-40%.

Watch how dental plaque can contribute to the development of VAP.





Bacteria found in ICU are different from those at home, therefore, the same brushing habits which are used at home do not apply to a patient in ICU.

The bacteria, which are responsible for plaque in ICU, may include Staphylococcus aureus (including MRSA), Burkholdia cepacia or Acinetobacter species. These may cause a serious problem for the patient in ICU.
Plaque, a bacterial biofilm, builds up very fast covering the complete tooth surface in as little as two hours. The Center for Disease Control (CDC) in the United States therefore recommends an oral intervention every two hours to reduce the incidence of VAP

The best product to remove plaque is a toothbrush with soft bristles. This will effectively remove the plaque on the surface and the interdental spaces. It is recommended to use a brush at least twice a day.
For patients with extremely sore gums, patients without teeth or those who require less traumatic oral care during the day, a soft suction swab or oral suction wand is sufficient.



Recommended brushing technique

The modified Bass brushing technique

The modified Bass brushing technique has been proven to be the most effective in removing plaque. A soft brush is placed at the gum line at a 45 degree angle. The brush is "wiggled" 3-5 times, then moved toward the end of the tooth. All of this is done without pressure. Click on the video to view this technique.

View the Canadian Dental Hygienist Association (CDHA) position paper on tooth brushing.







[1] : C.A. VAN NIEUWENHOVEN, E. BUSKENS, D.C. BERGMANS, F.H. VAN THIEL, G. RAMSAY et J.M. BONTEN, Oral decontamination is cost-saving in the prevention of ventilator associated pneumonia in intensive care units, 2004.

[2] : R.F. ABIDIA, Oral Care in the Intensive Care Unit : A Review, The Journal of Contemporary Dental Practice, Volume 8, No. 1, January 2007.

[3] : R. GARCIA, A review of the possible role of oral and dental colonization on the occurrence of health care-associated pneumonia: Underappreciated risk and a call for interventions, AJIC, November 2005.

[4] : R. GARCIA, L. JENDRESKY, L. COLBERT, A. BAILEY, M. ZAMAN et M. MAJUMDER, Reducing Ventilator-Associated Pneumonia Through Advanced Oral-Dental Care: A 48-Month Study, AJCC, July 2009.

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