This information is intended for Medical and Dental Professionals to explore detailed literature on the impact of Oral Disease on the rest of the body.
Presence of periodontopathic bacteria in coronary arteries from patients with chronic periodontitis.
Marcelino SL, Gaetti-Jardim E Jr, Nakano V, Canônico LA, Nunes FD, Lotufo RF, Pustiglioni FE, Romito GA, Avila-Campos MJ.
Department of Stomatology, University of São Paulo, SP, Brazil.
In this study the presence of periodontopathic pathogens in atheromatous plaques removed from coronary arteries of patients with chronic periodontitis and periodontally healthy subjects by PCR was detected. Our results indicate a significant association between the presence of Porphyromonas gingivalis and atheromas, and the periodontal bacteria in oral biofilm may find a way to reach arteries.
Sunday, January 04, 2009 For years there have been hints and hypotheses that heart disease and periodontal (gum) disease are associated or share common factors. Among the more humorous notions held by the uninformed press and public was that heart plaque and tooth plaque were somehow the same thing. That dubious notion notwithstanding there have long been provocative findings that have pointed to a relationship between a healthy mouth and a healthy heart.
The first and most widely studied theory was that the bacteria associated with periodontal disease (most notably Porphyromonas gingivalis) somehow traveled through the blood stream and provoked an inflammation response in the heart. Indeed, one of the first large studies (9760 participants over 17 years) found that “those with periodontitis had a 25% increased risk of coronary heart disease relative to those with minimal periodontal disease.” The link became even closer when a subsequent study determined that treating gum disease resulted in improved endothelial function and blood flow. Since then there have been numerous other studies that have detected a statistically significant association between gum disease and a variety of biomarkers for heart disease such as C-Reactive Protein (CRP) and Lipoprotein-associated Phospholipase A2 (Lp-PLA2).
One of the first direct links between periodontal and heart disease was found in a study that determined those with chronic periodontitis had higher triglyceride levels and a greater prevalence of small LDL a particularly powerful promoter of heart disease even among people with low cholesterol. The problem with these and many other studies is that it is often difficult to determine whether these similar biomarkers actually cause the disease or whether they are simply common indicators of a disease whose cause is some other common factor.
It could be that people without gum and/or heart disease simply live healthier, exercise, eat better, etc., than those with either or both diseases! However, for the first time, a study has shown that treating even mild gum disease in otherwise healthy people not only improves endothelial function but significantly reduces carotid intima media thickness (CIMT). That’s right, they found unequivocal evidence that treating gum disease regresses a standard measure of atherosclerosis.
To be fair, the study only looked at carotid arteries and not coronary arteries, it was a fairly small study (just 35 people), and CIMT is among these easiest markers of atherosclerotic lesions to regress. Head researcher Dr. Mario Clerici is quoted as stating, “The novelty ofthis study is that this is the first physical evidence that you can reverse a lesion that is already growing in the intima by doing something as simple as taking care of your gums . . . To tell you the truth, we were really surprised by the result, but it turned up in subject after subject.” The study involved nothing more than the simple removal of tartar and cleaning of the gums. There were no other procedures, no antibiotics or other prescription drugs or supplements, just the same basic dental hygiene measures you might receive at your dentist’s office.
Researchers used Echocardiography of carotid arteries to compare baseline CIMT against measurements made at several time points after treatment. They also measured common inflammatory biomarkers associated with cardiovascular risk. The study treatments resulted in significant reductions in CIMT at multiple sites as well as reductions in bacterial load and of the inflammation biomarkers. For the record, there is still much to be learned about the connection between heart disease and dental health. To recap the study was small, it only looked at carotid arteries not coronary arteries, and CIMT is perhaps the easiest atherosclerosis marker to regress. Nonetheless, we have the first solid evidence that there IS a connection between heart health and dental health. The takeaway heart health hint here is that you have another reason to follow the age-old admonition to visit your dentist regularly for a cleaning and check-up. You will now have two reasons to smile – whiter teeth and a potentially healthier heart.
The host’s reaction to foreign bodies known as an inflammatory response plays an important role in the etiology of cardiovascular disease. The physician is able to monitor this response by the serum levels of a blood protein called C-reactive protein or CRP. CRP levels in the blood have been shown to be predictive of a heart attack. In January of 2005 two papers were published that showed that if the blood levels of CRP were reduced, in these studies by prescription drugs known as statins, that the incidence of heart attacks were significantly decreased.
These studies indicate that the serum levels of CRP are an independent and modifiable risk factor for cardiovascular disease. But no one is quite sure what are the factors or conditions that cause the levels of CRP to increase in the blood. In most cases there are no acute infections or processes that can be associated with the elevated levels, leaving one to wonder what chronic, presumably asymptomatic condition is contributing to the high levels. In this context there is an emerging literature that suggests that dental infections, especially periodontal disease, could be playing a role. The connection is based on several observations that, while biologically plausible, lack the scientific rigor of a proven fact.
Could this man’s periodontal infection be a risk factor for cardiovascular disease?
In 1989 several cardiologists from Finland, i.e., Matilla, Syrjanen and their colleagues, reported that poor dental health could be associated with both an acute myocardial infarction and with a cerebral vascular accident. Subsequently, in a 7-year prospective study, dental disease as measured by the Total Dental Index (p=0.007), the number of previous myocardial infarctions (p=0.003), and to a lesser extent, diabetes (p=0.06), were associated with a risk of developing a new and often fatal myocardial infarction. Traditional risk factors, such as hypertension, smoking, total cholesterol levels, HDL cholesterol levels, triglycerides, social-economic status, gender and age were not significant predictors of a coronary event, when included in a model that contained the dental variables.
Other studies have generally confirmed this link between dental disease and coronary heart disease. A prospective cohort design study, involving data from 9,760 United States males examined three times between 1971 and 1987, found a significant relationship between either periodontitis or edentulism and coronary heart disease, even after adjusting for 13 known risk factors. A representative sample of 1,384 adult Finnish males, aged 45-64 years, showed that the number of missing teeth, along with hypertension, geographic area, and educational level were independent explanatory factors for the presence of ischemic heart disease. Among United States veterans participating in a longitudinal aging study, a significant association between periodontal disease, as measured by the extent of alveolar bone loss, and coronary heart disease and stroke could be demonstrated after adjusting for various cardiovascular risk factors.
We have been recording a large number of oral/dental variables in a group of elderly veterans, so as to study the relationship between oral/dental health and systemic diseases among older individuals. We found that a statistical association exists between a diagnosis of coronary heart disease and certain oral/dental parameters such as the numbers of missing teeth, plaque BANA test scores, salivary levels of certain bacteria and complaints of dry mouth or xerostomia. In logistic regression models, dentate individuals with 1 to 14 teeth were 2.81 times more likely to have coronary heart disease than individuals with most of their teeth, i.e., 15 to 28 teeth. A positive plaque BANA score, which indicates the presence of certain anaerobic bacteria in the plaque samples, was twice as likely to be found in dentate individuals with coronary heart disease, compared to dentate individuals without coronary heart disease. Individuals who complained of a dry mouth were 2.34 times more likely to have a diagnosis of coronary heart disease.
The dental/oral variables in these older individuals were more strongly associated with coronary heart disease than were recognized risk factors such as serum cholesterol levels, the body mass index and smoking status. This suggests that good dental health may be important in maintaining good cardiovascular health.
How could an inflammation about the gums cause disease on the linings of the arteries? Good question, as it is difficult to see how events occurring on the teeth or in the gum tissue could influence the development of an atheroma on the endothelial surface of arteries such as the coronary artery. A new paradigm is appearing in medicine that asks “are all diseases infections? This possibility was suggested by the demonstration that most ulcers are due to a treatable infection with Helicobacter pylori, and has been fueled in recent years by the association of chronic infections with cerebral and myocardial infarctions. Dental infections were not considered as contributory to these events, even though dental caries and periodontal disease are the most common of all chronic infections. It is well known that dental treatments, and dental infections can cause a bacteremia, and that this bacteremia has been associated with infective endocarditis.
Dental infections, involving the soft tissues of the periodontium and the pulp, can also elicit an inflammatory response that could release into the systemic circulation a variety of biologically active molecules. These bacterial products, such as lipopolysaccharides (LPS) and heat shock proteins (HSP), as well as inflammatory mediators such as cytokines, could directly or indirectly influence events on the intima of blood vessels. It is this propensity of dental infections to raise the white blood cell counts, to elicit a chronic inflammatory response, and/or an asymptomatic bacteremia, that will link dental disease with cardiovascular disease.
In the illustration shown below, smoking, which is a risk factor for both cardiovascular disease and periodontal infections, is shown to directly increase (upregulate) the number of adhesion molecules on the lining of endothelial cells. These adhesion molecules allow activated monocytes to attach to the lining of blood vessels and squeeze between the endothelial cells, causing an inflammatory response in the tissue below the endothelial cells. Smoking, however, promotes periodontal infections, which in turn releases LPS (lipopolysaccharide) molecules into the blood stream and these LPS molecules can also upregulate adhesion molecules. Other aspects of the inflammation in the gum tissues can also increase the blood levels of pro-inflammatory cytokines and acute phase proteins like the C-reactive proteins. The inflammation in the gum tissues can activate those monocytes which are capable of sticking to the adhesion molecules, which in turn can squeeze between the endothelial cells becoming tissue macrophages.
Several chronic infections can follow this pathway of upregulating adhesion molecules and activating monocytes. The best known of these are respiratory infections due to Chlamydia pneumonia. Dental infections, however, are far more common than C. pneumonia infections and are usually asymptomatic. The man whose periodontal infection is shown below had no symptoms and came to the dental clinic seeking a replacement for his missing front tooth. He was oblivious to his periodontal condition, even though there was bleeding and inflammation around most of his teeth. Based upon recent studies, if we had taken a blood sample of this man, the levels of known risk factors for atherosclerosis (white blood cell count, C-reactive protein level, HDL-cholesterol level and fibrinogen level) would all be higher than those in a comparably aged man without periodontal disease. It is the extent and pervasiveness of the periodontal infection that would make this a possible risk factor for cardiovascular disease.
If periodontal inflammation is shown to be a risk factor for either coronary artery disease or stroke (see Dental Disease and Cerebral Vascular Disease), then it will be considered a modifiable risk factor, since it can be treated. This means that the dentist and the patient will both be concerned with periodontal disease and the available treatment choices. (See Antimicrobial Agents in Periodontal Disease).
from Walter Loesche: http://www.dent.umich.edu/research/loeschelabs/
So many people think it’s natural and normal for their gums to bleed.
“I know I’m cleaning really well if I can make my gums bleed.”
“Oh, it’s just gingivitis.”
And to that I have to ask, Do your elbows bleed when you take a shower? Well, they shouldn’t, and neither should the gums.
Bleeding gums represent an open wound in one of the most contaminated parts of the body, bar none. And beyond bad breath there are a whole slew of effects on the whole rest of the body as the bacteria and bacterial waste-products seep down into the rest of the system: heart, blood vessels, lungs, kidneys, brain, reproductive organs, joints, etc., etc…. Some of these things can be deadly.
If the direct effects are not bad enough, there are secondary inflammatory stimulatory effects on the immune system, and these effects can lead to wide-ranging damage.
Clearly, this picture from Walter Loesche is WAY beyond gingivitis. But one can easily see the tremendous surface area of raw, exposed connective tissue and its associated vasculature, a pathway directly into the circulation. This is frank periodontitis. Gingivitis is much more subtle and hard to notice but can represent another great source of ingress into the bloodstream.
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- Cardiovascular disease
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Severe periodontitis is associated with systemic inflammation and a dysmetabolic status: a case-control study
bstract Background and Aim: A cluster of metabolic factors defines a syndrome that predisposes to diabetes and cardiovascular disease. Chronic infections such as periodontitis might alter these individual metabolic factors and the systemic inflammatory burden. The aim of this study was to investigate the association between severe periodontitis and increase in inflammatory and metabolic risk factors for cardiovascular disease. Materials and Methods: We examined 302 patients with severe periodontitis and 183 healthy controls, (more…)
Aetna and Columbia Announce Results from Study Showing Relationship between Periodontal Treatment and a Reduction in the Overall Cost of Care for Three Chronic Conditions
Aetna (NYSE:AET) and Columbia University College of Dental Medicine conducted a study that found a relationship between periodontal (gum) treatment and the overall cost of care for several chronic diseases. The results of the study, which included approximately 145,000 Aetna members with continuous dental and medical coverage, indicate that periodontal care appears to have a positive effect on the cost of medical care, with earlier treatment resulting in lower medical costs for members with diabetes, coronary artery disease (CAD), and cerebrovascular disease (CVD) or stroke.
“The results of this study are encouraging because they show the connection between good oral health and overall well-being, as well as illustrating that the early treatment of periodontal disease can help reduce medical costs for these conditions,” said Pat Farrell, head of Aetna Specialty Products. “We believe that in addition to lowering medical costs, we are also helping to improve members’ quality of life. We will continue to work with Columbia to demonstrate ways that dental care can improve the overall health of our members.”
“Systemic health is often associated with the condition of the oral cavity in that many systemic diseases manifest in the mouth; however, less is known about the connection between a diseased periodontium and the impact it may have on systemic health,” said David A. Albert, D.D.S., M.P.H., Associate Professor of Dentistry at Columbia University. “The association between periodontal infection and systemic health has important implications for the treatment and management of patients.”
The retrospective study of claims data included an examination of approximately 145,000 members participating in Aetna PPO plans with continuous dental and medical coverage over two years. Periodontal care appeared to have a positive effect on the cost of medical care in this two-year study (2001, 2002), with earlier treatment resulting in lower medical costs for diabetes, CVD and CAD. In addition, the actual cost of medical care for patients with diabetes and CAD was found to be lower if they received periodontal care in the first year of the study.
About Columbia University College of Dental Medicine
Since its inception in 1852 and its incorporation into Columbia University in 1917, the College of Dental Medicine has vigorously pursued its commitment to education, patient care and research. Recognizing the value to the public and the dental specialties, the college established the first formal specialty education program in orthodontics in the 1920s. Columbia went on to establish programs in periodontics, endodontics, oral/maxillofacial surgery, prosthodontics, pediatric dentistry and advanced programs. The college provides general dentistry, oral surgery, pediatric dentistry, orthodontics, and other clinic services to many members of the community through its Faculty Practice, Postgraduate and Specialty Practice, and Undergraduate Clinic. Columbia encourages and supports all forms of academic research efforts that have direct impact on improving oral health by fostering faculty and student participation in research and training students in current research methodologies.
ScienceDaily (Nov. 28, 2007) — A new study found that prevention of periodontal diseases may lead to savings on not only dental costs, but also medical care costs. Periodontal, or gum diseases have been linked to systemic health conditions including diabetes, cardiovascular disease, and respiratory problems.
The study, conducted in Japan, examined the effect of periodontal diseases on medical and dental costs in 4,285 patients over a 3.5 year time span. The patients were between the ages of 40-59. Researchers found that cumulative health care costs were 21% higher for those patients with severe periodontal disease than those with no periodontal disease. Severe periodontal disease, or periodontitis, involves bone loss and diminished attachment around the teeth.
“While previous studies have evaluated the potential link between periodontal diseases and other systemic conditions, this study provides an interesting analysis of total
health care costs and the financial impact of having periodontal diseases,” explained JOP editor Kenneth Kornman, DDS. “The research suggests that patients with severe periodontal diseases incur higher overall health care expenses as compared to those patients with no periodontal disease. Prevention of periodontal disease may be very important in overall health, and this study suggests that it may also indirectly translate into lower total health care costs.”
“Everyone is looking for ways to reduce health care costs,” said Susan Karabin, DDS, President of the American Academy of Periodontology. “Especially those who are in an age category where they are more susceptible to periodontal diseases. Because of the relationship between the mouth and the rest of the body, treating periodontal
disease may be one simple way to decrease total health care costs. If caught early, periodontal diseases can be treated using simple non-surgical techniques which can
restore your mouth to a healthy state.”
Journal of Periodontology article: “The effect of periodontal disease on medical and dental costs in a middle-aged Japanese population: A longitudinal worksite study,”
In July of 1998, the American Academy of Periodontology launched an effort to educate the public about new findings which support what dental professionals had long suspected: Infections in the mouth can play havoc elsewhere in the body.
Since July of 1998, evidence has continued to mount to support these links. While more research needs to be done to say definitively that people with periodontal disease are at higher risk for developing heart disease, stroke, uncontrolled diabetes, preterm births and respiratory disease, periodontists do know that periodontal disease is a bacterial infection, and all infections are cause for concern.
Periodontal bacteria can enter the blood stream and travel to major organs and begin new infections. Research is suggesting that this may:
Background: Periodontitis has recently been identified as a potential risk factor for systemic pathologies such as cardiovascular disease, the hypothesis being that periodontal pockets could release pro-inflammatory bacterial components, for instance endotoxins, into the bloodstream. It is known that the oral cavity can be a source of circulating bacteria, but this has never been shown for bacterial endotoxins, and no evidence exists so far that the risk of systemic injury is related to the severity of periodontitis. The aim of the present study was to test the influence of gentle mastication on the occurrence of endotoxemia in patients with or without periodontal disease.
Methods: A total of 67 subjects were periodontally examined and grouped according to their periodontal status. This classification was based on an original index of severity of periodontal disease (periodontal index for risk of infectiousness, PIRI) aimed at reflecting the individual risk of systemic injury from the periodontal niches. Thus, the patients were classified into 3 risk groups: low, PIRI = 0; n = 25; moderate, 1 ≤PIRI ≤5, n = 27; and high 6 ≤PIRI ≤10, n = 15. Blood samples were collected before and 5 to 10 minutes after a standardized session of gentle mastication for detection of circulating endotoxins. Blood samples were tested with a chromogenic limulus amoebocyte lysate assay.
Results: Overall, blood levels of endotoxin after mastication were found to be significantly higher than before mastication (0.89 ± 3.3 pg/ml versus 3.0 ± 5.8 pg/ml; P = 0.0002). Likewise, the incidence of positive endotoxemia rose from 6% before mastication to 24% after mastication (P = 0.001). When accounting for the PIRI index, endotoxin levels and positive endotoxemia proved to be significantly higher in patients with severe periodontal disease than in the subjects with low or moderate periodontitis.
Conclusions: Gentle mastication is able to induce the release of bacterial endotoxins from oral origin into the bloodstream, especially when patients have severe periodontal disease. This finding suggests that a diseased periodontium can be a major and underestimated source of chronic, or even permanent, release of bacterial pro-inflammatory components into the bloodstream.
Seymour GJ, Ford PJ, Cullinan MP, Leishman S, Yamazaki K.
Faculty of Dentistry, University of Otago, Dunedin, New Zealand. email@example.com
Oral conditions such as gingivitis and chronic periodontitis are found worldwide and are among the most prevalent microbial diseases of mankind. The cause of these common inflammatory conditions is the complex microbiota found as dental plaque, a complex microbial biofilm. Despite 3000 years of history demonstrating the influence of oral status on general health, it is only in recent decades that the association between periodontal diseases and systemic conditions such as coronary heart disease and stroke, and a higher risk of preterm low birth-weight babies, has been realised. Similarly, recognition of the threats posed by periodontal diseases to individuals with chronic diseases such as diabetes, respiratory diseases and osteoporosis is relatively recent. Despite these epidemiological associations, the mechanisms for the various relationships remain unknown. Nevertheless, a number of hypotheses have been postulated, including common susceptibility, systemic inflammation with increased circulating cytokines and mediators, direct infection and cross-reactivity or molecular mimicry between bacterial antigens and self-antigens. With respect to the latter, cross-reactive antibodies and T-cells between self heat-shock proteins (HSPs) and Porphyromonas gingivalis GroEL have been demonstrated in the peripheral blood of patients with atherosclerosis as well as in the atherosclerotic plaques themselves. In addition, P. gingivalis infection has been shown to enhance the development and progression of atherosclerosis in apoE-deficient mice. From these data, it is clear that oral infection may represent a significant risk-factor for systemic diseases, and hence the control of oral disease is essential in the prevention and management of these systemic conditions.
by Marlowe HoodWed Sep 10, 7:16 PM ET
Here’s another reason to brush your teeth: poor dental hygiene boosts the risk of heart attacks and strokes, a pair of studies reported this week.
Heart disease is the number one killer worldwide, claiming upward of 17 million lives every year, according to the World Health Organization.
Smoking, obesity and high cholesterol are the most common culprits, but the new research shows that neglected gums can be added to the list.
“We now recognize that bacterial infections are an independent risk factor for heart diseases,” said Howard Jenkins of the University of Bristol in Britain, at a meeting of the Society for General Microbiology in Dublin.
“In other words, it doesn’t matter how fit, slim or healthy you are, you’re adding to your chances of getting heart disease by having bad teeth,” the professor said.
There are up to 700 different bacteria in the human mouth, and failing to scrub one’s pearly whites helps those germs to flourish.
Most are benign, and some are essential to good health. But a few can trigger a biological cascade leading to diseases of the arteries linked to heart attacks and stroke, according to the new research.
“The mouth is probably the dirtiest place in the human body,” Steve Kerrigan of the Royal College of Surgeons in Dublin said.
“If you have an open blood vessel from bleeding gums, bacteria will gain entry to your bloodstream.”
Once inside the blood, certain bacteria stick onto cells called platelets, causing them to clot inside the vessel and thus decreasing blood flow to the heart.
“We mimicked the pressure inside the blood vessels and in the heart, and demonstrated that bacteria use different mechanisms to cause platelets to clump together, allowing them to completely encase the bacteria,” he said.
This not only created conditions that can provoke heart attacks and strokes, it also shielded the bacteria from both, immune system cells and antibiotics.
“These findings suggest why antibiotics do not always work in the treatment of infectious heart disease,” Jenkins said.
In separate research, a team led by Greg Seymour of the University of Otago Dunedin in New Zealand showed how other bacteria from the mouth can provoke atherosclerosis, a disease that causes hardening of the arteries.
All organisms — including humans and bacteria — produce “stress proteins,” molecules produced by conditions such as inflammation, toxins, starvation, or oxygen deprivation.
One function of stress proteins is to guide other proteins across cell membranes.
But they can also can latch onto foreign objects, called antigens, and deliver then to immune cells, provoking an immune reactions in the body.
Normally, the body does not attack its own stress proteins.
But bacterial stress proteins — which are similar — do trigger a response, and once that has happened the immune system can no longer differentiate between the two, said Seymour.
“White blood cells can build up in the tissue of arteries, causing atherosclerosis,” he explained in a phone interview.
Copyright © 2008 Agence France Presse
ScienceDaily (Dec. 15, 2008) — Hospital-borne infections are a serious risk of a long-term hospital stay, and ventilator-associated pneumonia (VAP), a lung infection that develops in about 15% of all people who are ventilated, is among the most dangerous. With weakened immune systems and a higher
resistance to antibiotics, patients who rely on a mechanical ventilator can easily develop serious infections — as 26,000 Americans do every year.
Thanks to a proven new clinical approach developed by Tel Aviv University nurses, though, there is a new tool for stopping the onset of VAP in hospitals.
This new high-tech tool? An ordinary toothbrush.
Three Times a Day Keeps Pneumonia Away
“Pneumonia is a big problem in hospitals everywhere, even in the developed world,” says Nurse Ofra Raanan, the chief researcher in the new study and a lecturer at Tel Aviv University’s Department of Nursing. “Patients who are intubated can be contaminated with pneumonia only 2 or 3 days after the tube is put in place. But pneumonia can be effectively prevented if the right measures are taken.”
Raanan, who works at the Sheba Academic School of Nursing at The Chaim Sheba Medical Center, collaborated with a team of nurses at major medical centers around Israel. The nurses found that if patients — even unconscious ones — have their teeth brushed three times a day, the onset of pneumonia can be reduced by as much as 50%.
A Pioneering Study with Measurable Effects
It’s difficult to quantify the effects precisely, the researchers say. “While the research shows a definite improvement in reducing the incidence of hospital-borne pneumonia, it’s hard to say by exactly how much toothbrushing prevents VAP,” says Raanan, but the published evidence shows a direct correlation for intubated patients.
“Sometimes, however, doctors and nurses do everything right and the patient still gets pneumonia. But this approach will certainly improve the odds for survival.”
Normally, the teeth and oral cavity in a healthy mouth maintain a colony of otherwise harmless bacteria. Infection takes root when a breathing tube allows free passage of the “good” bacteria into the lower parts of the lung. The bacteria travel in small water droplets through the tube and colonize the lung. Once there, the bacteria take advantage of a patient’s weakened immune system and multiply. A regular toothbrushing kills the growth and subsequent spread of the bacterium that leads to VAP.
Augmenting the Preventative Routine
There are additional steps for preventing the onset of VAP. Today, nurses typically use a mechanical suction device to remove secretions from the mouth and throat. They also put patients in a seated position and change the position every few hours. Toothbrushing, say Tel Aviv University nurses, should be added to the routine.
Although nurses in some American hospitals already practice toothbrushing on ventilated patients, these new results may convince medical centers around the world to invest more resources in this routine practice, thereby saving lives.