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Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia

  1. Zongdao Shi1,
  2. Huixu Xie1,
  3. Ping Wang2,
  4. Qi Zhang3,
  5. Yan Wu4,
  6. E Chen5,
  7. Linda Ng6,
  8. Helen V Worthington7,
  9. Ian Needleman8,
  10. Susan Furness7,*

Editorial Group: Cochrane Oral Health Group

Published Online: 13 AUG 2013

Assessed as up-to-date: 14 JAN 2013

DOI: 10.1002/14651858.CD008367.pub2


How to Cite

Shi Z, Xie H, Wang P, Zhang Q, Wu Y, Chen E, Ng L, Worthington HV, Needleman I, Furness S. Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD008367. DOI: 10.1002/14651858.CD008367.pub2.

Author Information

  1. 1

    West China College of Stomatology, Sichuan University, Department of Oral and Maxillofacial Surgery, State Key Laboratory of Oral Diseases, Chengdu, Sichuan, China

  2. 2

    West China College of Stomatology, Sichuan University, Department of Dental Implantation, Chengdu, Sichuan, China

  3. 3

    West China College of Stomatology, Sichuan University, Department of Oral Implantology, State Key Laboratory of Oral Diseases, Chengdu, Sichuan, China

  4. 4

    Chongqing Medical University, Department of Orthodontics, Chongqing, China

  5. 5

    West China College of Stomatology, Sichuan University, Department of Paediatric Dentistry, Chengdu, Sichuan, China

  6. 6

    University of Queensland, School of Nursing and Midwifery, South Brisbane, Queensland, Australia

  7. 7

    School of Dentistry, The University of Manchester, Cochrane Oral Health Group, Manchester, UK

  8. 8

    UCL Eastman Dental Institute, Unit of Periodontology and International Centre for Evidence-Based Oral Healthcare, London, UK

*Susan Furness, Cochrane Oral Health Group, School of Dentistry, The University of Manchester, Coupland III Building, Oxford Road, Manchester, M13 9PL, UK. Susan.Furness@manchester.ac.uk. suefurness@gmail.com.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 13 AUG 2013

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References

References to studies included in this review

  1. References to studies included in this review
  2. References to studies excluded from this review
  3. References to studies awaiting assessment
  4. References to ongoing studies
  5. Additional references
Bellissimo-Rodrigues 2009 {published data only}
  • Bellissimo-Rodrigues F, Bellissimo-Rodrigues WT, Viana JM, Teixeira GC, Nicolini E, Auxiliadora-Martins M, et al. Effectiveness of oral rinse with chlorhexidine in preventing nosocomial respiratory tract infections among intensive care unit patients. Infection Control & Hospital Epidemiology 2009;30(10):952-8.
Berry 2011 {published data only}
  • Berry AM, Davidson PM, Masters J, Rolls K, Ollerton R. Effects of three approaches to standardized oral hygiene to reduce bacterial colonization and ventilator associated pneumonia in mechanically ventilated patients: A randomised control trial. International Journal of Nursing Studies 2011;48(6):681-8.
Bopp 2006 {published data only}
  • Bopp M, Darby M, Loftin KC, Broscious S. Effects of daily oral care with 0.12% chlorhexidine gluconate and a standard oral care protocol on the development of nosocomial pneumonia in intubated patients: a pilot study. Journal of Dental Hygiene 2006;80(3):9.
Cabov 2010 {published and unpublished data}
  • Cabov T, Macan D, Husedzinovic I, Skrlin-Subic J, Bosnjak D, Sestan-Crnek S, et al. The impact of oral health and 0.2% chlorhexidine oral gel on the prevalence of nosocomial infections in surgical intensive-care patients: a randomized placebo-controlled study. Wiener Klinische Wochenschrift 2010;122(13-14):397-404.
Caruso 2009 {published data only}
  • Caruso P, Denari S, Ruiz SAL, Demarzo SE, Deheinzelin D. Saline instillation before tracheal suctioning decreases the incidence of ventilator-associated pneumonia. Critical Care Medicine 2009;37(1):32-8.
Chen 2008 {published data only}
  • Chen QL, Ye XF, Jiang YZ, Yan MQ. Application of new oral care method to orotracheal intubation. Fujian Medical Journal 2008;30(5):155-7.
DeRiso 1996 {published data only}
  • DeRiso AJ 2nd, Ladowski JS, Dillon TA, Justice JW, Peterson AC. Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery. Chest 1996;109(6):1556-61.
Feng 2012 {published data only}
  • Feng S,  Sun X,  Chen Y. Application of different mouthwashes in oral nursing for patients with orotracheal intubation. China Medicine and Pharmacy 2012;8(2):100-1.
Fields 2008 {published data only}
  • Fields LB. Oral care intervention to reduce incidence of ventilator-associated pneumonia in the neurologic intensive care unit. Journal of Neuroscience Nursing 2008;40(5):291-8.
Fourrier 2000 {published data only}
  • Fourrier F, Cau-Pottier E, Boutigny H, Roussel-Delvallez M, Jourdain M, Chopin C. Effects of dental plaque antiseptic decontamination on bacterial colonization and nosocomial infections in critically ill patients. Intensive Care Medicine 2000;26(9):1239-47.
Fourrier 2005 {published data only}
  • Fourrier F, Dubois D, Pronnier P, Herbecq P, Leroy O, Desmettre T, et al. Effect of gingival and dental plaque antiseptic decontamination on nosocomial infections acquired in the intensive care unit: a double-blind placebo-controlled multicenter study. Critical Care Medicine 2005;33(8):1728-35.
Grap 2004 {published data only}
  • Grap MJ, Munro CL, Elswick RK Jr, Sessler CN, Ward KR. Duration of action of a single, early oral application of chlorhexidine on oral microbial flora in mechanically ventilated patients: a pilot study. Heart & Lung 2004;33(2):83-91.
Grap 2011 {published data only}
  • Grap MJ, Munro CL, Hamilton VA, Elswick RK Jr, Sessler CN, Ward KR. Early, single chlorhexidine application reduces ventilator-associated pneumonia in trauma patients. Heart & Lung 2011;40(5):e115-22.
Hu 2009 {published data only}
  • Hu X, Chen X. Application of improved oral nursing method to orotracheal intubation. Chinese Journal of Misdiagnostics 2009;9(17):4058-9.
Jacomo 2011 {published data only}
  • Jacomo AD, Carmona F, Matsuno AK, Manso PH, Carlotti AP. Effect of oral hygiene with 0.12% chlorhexidine gluconate on the incidence of nosocomial pneumonia in children undergoing cardiac surgery. Infection Control & Hospital Epidemiology 2011;32(6):591-6.
Koeman 2006 {published data only}
  • Koeman M, van der Ven AJ, Hak E, Joore HC, Kaasjager K, de Smet AG, et al. Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia. American Journal of Respiratory & Critical Care Medicine 2006;173(12):1348-55.
  • Koeman M, van der Ven AJ, Hak E, Joore JC, Kaasjager HA, de Smet AM, et al. Less ventilator-associated pneumonia after oral decontamination with chlorhexidine; a randomised trial. Nederlands Tijdschrift voor Geneeskunde 2008;152(13):752-9.
Kusahara 2012 {published data only}
  • Kusahara DM, Peterlini MA, Pedreira ML. Oral care with 0.12% chlorhexidine for the prevention of ventilator-associated pneumonia in critically ill children: Randomised, controlled and double blind trial. International Journal of Nursing Studies 2012;49(11):1354-63.
  • Kusahara DM, Peterlini MAS, Pedreira MLG. Randomized, controlled and double blinded trial of oral decontamination with 0.12% chlorhexidine for the prevention of ventilator-associated pneumonia in children. Pediatric Critical Care Medicine 2011;12(3, Suppl 1):A16.
  • Pedreira MLG, Kusahara DM, de Carvalho WB, Nunez SC, Peterlini MAS. Oral care interventions and oropharyngeal colonization in children receiving mechanical ventilation. American Journal of Critical Care 2009;18(4):319-29.
Long 2012 {published data only}
  • Long Y, Mou G, Zuo Y, lv F, Feng Q, Du J. Effect of modified oral nursing method on the patients with orotracheal intubation. Journal of Nurses Training 2012;27(24):2290-3.
Lorente 2012 {published data only}
  • Lorente L, Lecuona M, Jimenez A, Palmero S, Pastor E, Lafuente N, et al. Ventilator-associated pneumonia with or without toothbrushing: a randomized controlled trial. European Journal of Clinical Microbiology and Infectious Diseases 2012;31(10):2621-9.
McCartt 2010 {published data only}
  • McCartt PAM. Effect of Chlorhexidine Oral Spray versus Mechanical Toothbrushing and Chlorhexindine Rinse in Decreasing Ventilator Associated Pneumonia in Critically Ill Adults [PhD thesis]. Gainesville, Florida, USA: University of Florida, 2010:91.
Munro 2009 {published data only}
  • Munro C, Grap M, Sessler C, McClish D. Effect of oral care interventions on dental plaque in mechanically ventilated ICU adults. American Journal of Critical Care 2007;16(3):309.
  • Munro CL, Grap MJ, Jones DJ, McClish DK, Sessler CN. Chlorhexidine, toothbrushing, and preventing ventilator-associated pneumonia in critically ill adults. American Journal of Critical Care 2009;18(5):428-37.
Needleman 2011 {published data only}
Ozcaka 2012 {published data only}
Panchabhai 2009 {published data only}
  • Panchabhai TS, Dangayach NS, Krishnan A, Kothari VM, Karnad DR. Oropharyngeal cleansing with 0.2% chlorhexidine for prevention of nosocomial pneumonia in critically ill patients: an open-label randomized trial with 0.01% potassium permanganate as control. Chest 2009;135(5):1150-6.
Pobo 2009 {published data only}
  • Pobo A, Lisboa T, Rodriguez A, Sole R, Magret M, Trefler S, et al. A randomized trial of dental brushing for preventing ventilator-associated pneumonia. Chest 2009;136(2):433-9.
Prendergast 2012 {published data only}
  • Prendergast V. Safety and efficacy of oral care for intubated neuroscience intensive care patients. Doctoral Dissertation Series 2012-3. Lund, Sweden: Lund University, 2012:1-86.
  • Prendergast V, Hagell P, Hallberg IR. Electric versus manual tooth brushing among neuroscience ICU patients: is it safe?. Neurocritical Care 2011;14(2):281-6.
  • Prendergast V, Hallberg IR, Jakobsson U, Renvert S, Moran A, Gonzalez O. Comparison of oropharyngeal and respiratory nosocomial bacteria between two methods of oral care: A randomized controlled trial. Journal of Neuroscience and Neurosurgical Nursing 2012;1(1):10-18.
  • Prendergast V, Jakobsson U, Renvert S, Hallberg IR. Effects of a standard versus comprehensive oral care protocol among intubated neuroscience ICU patients: results of a randomized controlled trial. Journal of Neuroscience Nursing 2012;44(3):134-46.
Roca Biosca 2011 {published data only}
  • Roca Biosca A, Anguera Saperas L, García Grau N, Rubio Rico L, Velasco Guillén MC. Prevention of mechanical ventilator-associated pneumonia: a comparison of two different oral hygiene methods. Enfermería Intensiva 2011;22(3):104-11.
Scannapieco 2009 {published data only}
  • Scannapieco FA, Yu J, Raghavendran K, Vacanti A, Owens SI, Wood K, et al. A randomized trial of chlorhexidine gluconate on oral bacterial pathogens in mechanically ventilated patients. Critical Care 2009;13(4):R117.
Sebastian 2012 {published data only}
  • Sebastian MR, Lodha R, Kapil A, Kabra SK. Oral mucosal decontamination with chlorhexidine for the prevention of ventilator-associated pneumonia in children - a randomized, controlled trial. Pediatric Critical Care Medicine 2012;13:e305-10.
Seguin 2006 {published data only}
  • Seguin P, Tanguy M, Laviolle B, Tirel O, Malledant Y. Effect of oropharyngeal decontamination by povidone-iodine on ventilator-associated pneumonia in patients with head trauma. Critical Care Medicine 2006;34(5):1514-9.
Tantipong 2008 {published data only}
  • Silvestri L, van Saene HK, Milanese M, Zei E, Blazic M. Prevention of ventilator-associated pneumonia by use of oral chlorhexidine. Infection Control & Hospital Epidemiology 2009;30(1):101-3.
  • Tantipong H, Morkchareonpong C, Jaiyindee S, Thamlikitkul V. Randomized controlled trial and meta-analysis of oral decontamination with 2% chlorhexidine solution for the prevention of ventilator-associated pneumonia. Infection Control & Hospital Epidemiology 2008;29(2):131-6.
Xu 2007 {published data only}
  • Xu J, Feng B, He L, Shen H, Chen XY. Influence of different oral nursing methods on ventilator-associated pneumonia and oral infection in the patients undergoing mechanical ventilation. Journal of Nursing Science 2007;7(22):56-7.
Xu 2008 {published data only}
  • Xu HL. Application of improved oral nursing method to the prevention of ventilator-associated pneumonia. Journal of Qilu Nursing 2008;14(19):15-6.
Yao 2011 {published data only}
  • Yao L, Chang C, Wang C, Chen C. Effect of an oral care protocol in preventing ventilator associated pneumonia in ICU patients. Critical Care 2008;12(Suppl 2):Abs No P48.
  • Yao LY, Chang CK, Maa SH, Wang C, Chen CC. Brushing teeth with purified water to reduce ventilator-associated pneumonia. Journal of Nursing Research 2011;19(4):289-97.
Zhao 2012 {published data only}
  • Zhao Y. Research on application of Yikou gargle in prevention of ventilation associated pneumonia. Chinese Journal of Nosocomiology 2012;23(22):5232-3.

References to studies excluded from this review

  1. References to studies included in this review
  2. References to studies excluded from this review
  3. References to studies awaiting assessment
  4. References to ongoing studies
  5. Additional references
Abusibeih 2010 {published data only}
Bordenave 2011 {published data only}
  • Bordenave C. Evaluation of the effectiveness of a protocol of intensification of mouth care (teeth brushing and chlorhexidine 0.12%) on the colonisation of tracheal aspirations in intubated and ventilated patients in intensive care. Recherche en Soins Infirmiers 2011;(106):92-8.
Chao 2009 {published data only}
Epstein 1994 {published data only}
Fan 2012 {published data only}
  • Fan T. The effect of a modified oral nursing care method on prevention of ventilator associated pneumonia. Nursing Practice and Research 2012;9(12):99-100.
Ferozali 2007 {published data only}
  • Ferozali F, Johnson G, Cavagnaro A. Health benefits and reductions in bacteria from enhanced oral care . Special Care in Dentistry 2007;27(5):168-76.
Genuit 2001 {published data only}
  • Genuit T, Bochicchio G, Napolitano LM, McCarter RJ, Roghman MC. Prophylactic chlorhexidine oral rinse decreases ventilator-associated pneumonia in surgical ICU patients. Surgical Infections 2001;2(1):5-18.
Guo 2007 {published data only}
  • Guo MJ. Study on the new oral nursing for the patient of acute lung brain-storm through tracheal. Chinese Journal of Modern Nursing 2007;13(26):2537-8.
Houston 2002 {published data only}
  • Houston S, Hougland P, Anderson JJ, LaRocco M, Kennedy V, Gentry LO. Effectiveness of 0.12% chlorhexidine gluconate oral rinse in reducing prevalence of nosocomial pneumonia in patients undergoing heart surgery. American Journal of Critical Care 2002;11(6):567-70.
Lai 1997 {published data only}
  • Lai M, Huang H. Toothpaste mouth care for critically ill patients. Journal of Nursing Science 1997;12(2):106-7.
Li 2011 {published data only}
  • Li W, Ma X, Peng Y, Cao J, Loo WTY, Hao L, et al. Application of a Nano-antimicrobial film to prevent ventilator-associated pneumonia: A pilot study. African Journal of Biotechnology 2011;10(10):1926-31.
Li 2012 {published data only}
  • Li S, Zhang H, Zhang B. Application of different oral nursing methods to prevent ventilation associated pneumonia. Practical Clinical Medicine 2012;13(5):92-3.
Liang 2007 {published data only}
  • Liang YL, Lu LQ, Liang JT. Oral cavity nursing study in endotracheal intubation with the Baihu decoction. Journal of Nurses Training 2007;1(22):79-80.
Liwu 1990 {published data only}
  • Liwu A. Oral hygiene in intubated patients. The Australian Journal of Advanced Nursing 1990;7(2):4-7.
MacNaughton 2004 {published data only}
  • MacNaughton PD, Bailey J, Donlin N, Branfield P, Williams A, Rowswell H. A randomised controlled trial assessing the efficacy of oral chlorhexidine in ventilated patients (029). Intensive Care Medicine 2004;30(Suppl):S12.
McCoy 2012 {published data only}
  • McCoy T, Fields W, Kent N. Evaluation of emergency department evidence-based practices to prevent the incidence of ventilator-acquired pneumonia. Journal of Nursing Care Quality 2012;27(1):83-8.
Ogata 2004 {published data only}
  • Ogata J, Minami K, Miyamoto H, Horishita T, Ogawa M, Sata T, et al. Gargling with povidone-iodine reduces the transport of bacteria during oral intubation. Canadian Journal of Anaesthesia 2004;51(9):932-6.
Pawlak 2005 {published data only}
  • Pawlak D, Semar R, Cantos K. Improving frequency of oral care in the medical intensive care unit. American Journal of Infection Control 2005;33(5):E147.
Santos 2008 {published data only}
  • Santos PSdS, Mello WR, Wakim RCS, Paschoal MÂG. Use of oral rinse with enzymatic system in patients totally dependent in the intensive care unit [Uso de solução bucal com sistema enzimático em pacientes totalmente dependentes de cuidados em unidade de terapia intensiva]. Revista Brasileira de Terapia Intensiva 2008;20(2):154-9.
Segers 2006 {published data only}
  • Segers P, Speekenbrink RG, Ubbink DT, van Ogtrop ML, de Mol BA. Prevention of nosocomial infection in cardiac surgery by decontamination of the nasopharynx and oropharynx with chlorhexidine gluconate: a randomized controlled trial. JAMA 2006;296(20):2460-6.
Ueda 2004 {published data only}
Wang 2006 {published data only}
  • Wang MM. The improvement of oral care in ICU intubated patients. Journal of Mudanjiang Medical College 2006;27(5):80-1.
Wang 2012 {published data only}
  • Wang YX, He LY, Gao MR, Wang ZW, Li XY. Application of oral nursing care bundle to prevent VAP for critically surgically ill patients. Chinese Archives of General Surgery 2012;6(5):448-50.
Yin 2004 {published data only}
  • Yin XR, Liao Y. The improvement of the oral care for patients with orotracheal intubation. West China Medical Journal 2004;19(3):482.
Zouka 2010 {published data only}
  • Zouka M, Soultati I, Hari H, Pourzitaki C, Paroutsidou G, Thomaidou E, et al. Oral dental hygiene and ventilator-associated pneumonia prevention in an ICU setting: Comparison between two methods (preliminary data of a randomised prospective study). Intensive Care Medicine 2010;36:S103.

References to studies awaiting assessment

  1. References to studies included in this review
  2. References to studies excluded from this review
  3. References to studies awaiting assessment
  4. References to ongoing studies
  5. Additional references
Anon 2012 {published data only}
  • Anon. EB57 Development of an oral care-based programme for prevention of ventilator-associated pneumonia. Critical Care Nurse 2012;32(2):e34.
Baradari 2012 {published data only}
  • Baradari AG, Khezri HD, Arabi S. Comparison of antibacterial effects of oral rinses chlorhexidine and herbal mouth wash in patients admitted to intensive care unit. Bratislavske Lekarske Listy 2012;113(9):556-60.
Seo 2011 {published data only}
  • Seo H-K, Choi E-H, Kim J-H. The effect of oral hygiene for ventilator-associated pneumonia (VAP) incidence. Journal of Korean Critical Care Nursing 2011;4(2):1.
Yun 2011 {published data only}
  • Yun H-Y, Lee E-S, Kim J-Y, Kim H-S, Kim K-A, Kim E-S, et al. Effect of tooth-brushing on oral health and ventilator-associated pneumonia of critically ill patients. Journal of Korean Critical Care Nursing 2011;4(2):1.

References to ongoing studies

  1. References to studies included in this review
  2. References to studies excluded from this review
  3. References to studies awaiting assessment
  4. References to ongoing studies
  5. Additional references
NCT 01657396 {unpublished data only}
  • Implementation and evaluation of revised protocols for oral hygiene for mechanically ventilated patients. Ongoing study July 2012 (currently recruiting).

Additional references

  1. References to studies included in this review
  2. References to studies excluded from this review
  3. References to studies awaiting assessment
  4. References to ongoing studies
  5. Additional references
Alhazzani 2013
  • Alhazzani W, Smith O, Muscedere J, Medd J, Cook D. Toothbrushing for critically ill mechanically ventilated patients: a systematic review and meta-analysis of randomized trials evaluating ventilator-associated pneumonia. Critical Care Medicine 2013;41(2):646-55.
Apostolopoulou 2003
  • Apostolopoulou E, Bakakos P, Katostaras T, Gregorakos L. Incidence and risk factors for ventilator-associated pneumonia in 4 multidisciplinary intensive care units in Athens. Respiratory Care 2003;48(7):681-8.
ATS Guideline 2005
  • American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. American Journal of J Respiratory and Critical Care Medicine 2005;171(4):388-416.
Azarpazhooh 2006
Azoulay 2006
  • Azoulay E, Timsit JF, Tafflet M, de Lassence A, Darmon M, Zahar JR, et al. Candida colonization of the respiratory tract and subsequent pseudomonas ventilator-associated pneumonia. Chest 2006;129(1):110-7.
Bekaert 2011
  • Bekaert M, Timsit JF, Vansteelandt S, Depuydt P, Vésin A, Garrouste-Orgeas M, et al. Attributable mortality of ventilator-associated pneumonia: a reappraisal using causal analysis. American Journal of Respiratory and Critical Care Medicine 2011;184(10):1133-9.
Berry 2007
  • Berry AM, Davidson PM, Masters J, Rolls K. Systematic literature review of oral hygiene practices for intensive care patients receiving mechanical ventilation. American Journal of Critical Care 2007;16(6):552-62.
Cook 1998
  • Cook DJ, Walter SD, Cook RJ, Griffith LE, Guyatt GH, Leasa D, et al. Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients. Annals of Internal Medicine 1998;29(6):433-46.
D'Amico 2009
Edwards 2009
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El-Solh 2004
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Estes 1995
Fourrier 1998
  • Fourrier F, Duvivier B, Boutigny H, Roussel-Delvallez M, Chopin C. Colonization of dental plaque: a source of nosocomial infections in intensive care unit patients. Critical Care Medicine 1998;26(2):301-8.
Garrouste-Orgeas 1997
  • Garrouste-Orgeas M, Chevret S, Arlet G, Marie O, Rouveau M, Popoff N, et al. Oropharyngeal or gastric colonization and nosocomial pneumonia in adult intensive care unit patients. A prospective study based on genomic DNA analysis. American Journal of Respiratory and Critical Care Medicine 1997;156(5):1647-55.
Gu 2012
  • Gu WJ, Gong YZ, Pan L, Ni YX, Liu JC. Impact of oral care with versus without toothbrushing on the prevention of ventilator-associated pneumonia: a systematic review and meta-analysis of randomized controlled trials. Critical Care 2012;16:R190.
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Hao 2011
Higgins 2011
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Labeau 2011
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Marsh 2010
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McCarney 2007
Melsen 2011
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Mojon 2002
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Muscedere 2008
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Pineda 2006
Pugin 1991
  • Pugin J, Auckenthaler R, Mili N, Janssens JP, Lew PD, Suter PM. Diagnosis of ventilator-associated pneumonia by bacteriologic analysis of bronchoscopic and nonbronchoscopic 'blind' bronchoalveolar lavage fluid. American Review of Respiratory Disease 1991;143(5 Pt 1):1121-9.
Scannapieco 1992
Schulz 2002
Selim 2010
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Shi 2004
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Tablan 2004
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Terezakis 2011
Terpenning 2005
Treloar 1995
  • Treloar DM, Stechmiller JK. Use of a clinical assessment tool for orally intubated patients. American Journal of Critical Care 1995;4(5):355-60.
Whittaker 1996
Zanatta 2011
  • Zanatta FB, Bergoli AD, Werle SB, Antoniazzi RP. Biofilm removal and gingival abrasion with medium and soft toothbrushes. Oral Health and Preventive Dentistry 2011;9(2):177-83.