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2007 American Association of Critical-Care Nurses
Am J Crit Care. 2007;16: 552-562
Angela M. Berry, Patricia M. Davidson, Janet Masters and Kaye Rolls
Patients Receiving Mechanical Ventilation
Systematic Literature Review of Oral Hygiene Practices for Intensive Care
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By Angela M. Berry, RN, BAppSc, MHthSc, Patricia M. Davidson, RN, BA, MEd, PhD,
Janet Masters, RN, BHSc (Nur), MN, and Kaye Rolls, RN, BAS
Background Oropharyngeal colonization with pathogenic
organisms contributes to the development of ventilator-
associated pneumonia in intensive care units. Although con-
sidered basic and potentially nonessential nursing care, oral
hygiene has been proposed as a key intervention for reduc-
ing ventilator-associated pneumonia. Nevertheless, evidence
from randomized controlled trials that could inform best
practice is limited.
Objective To appraise the peer-reviewed literature to deter-
mine the best available evidence for providing oral care to
intensive care patients receiving mechanical ventilation and to
document a research agenda for this important activity in opti-
mizing patients outcomes.
Methods Articles published from 1985 to 2006 in English and
indexed in the CINAHL, MEDLINE, Joanna Briggs Institute,
Cochrane Library, EMBASE, and DARE databases were
searched by using the key terms oral hygiene, oral hygiene
practices, oral care, mouth care, mouth hygiene, intubated,
mechanically ventilated, intensive care, and critical care. Refer-
ence lists of retrieved journal articles were searched for publi-
cations missed during the primary search. Finally, the Google
search engine was used to do a comprehensive search of the
World Wide Web to ensure completeness of the search. The
search strategy was verified by a health librarian.
Results The search yielded 55 articles: 11 prospective con-
trolled trials, 20 observational studies, and 24 descriptive
reports. Methodological issues and the heterogeneity of sam-
ples precluded meta-analysis.
Conclusions Despite the importance of providing oral hygiene to
intensive care patients receiving mechanical ventilation, high-
level evidence from rigorous randomized controlled trials or
high-quality systematic reviews that could inform clinical practice
is scarce. (American Journal of Critical Care. 2007;16:552-563)
552 AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2007, Volume 16, No. 6 www.ajcconline.org
SYSTEMATIC LITERATURE
REVIEW OF ORAL HYGIENE
PRACTICES FOR INTENSIVE
CARE PATIENTS RECEIVING
MECHANICAL VENTILATION
Evidence-Based Practice in Critical Care
C E
1.5 Hours
Notice to CE enrollees:
A closed-book, multiple-choice examination
following this article tests your under standing of
the following objectives:
1. Describe important strategies to decrease
ventilator-associated pneumonia.
2. Compare different studies that examine
various oral hygiene methods.
3. Analyze the results of different studies of oral
hygiene practices.
To read this article and take the CE test online,
visit www.ajcconline.org and click CE Articles in
This Issue. No CE test fee for AACN members.
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In their guidelines for preventing healthcare-
associated pneumonia,
2
the Centers for Disease Con-
trol and Prevention recommend the development
and implementation of a comprehensive oral hygiene
program, potentially with the inclusion of an anti-
septic agent, for settings where patients are at risk
for hospital-acquired pneumonia. In support of this
recommendation, researchers
3,4
have advocated oral
hygiene (and a subsequent reduction in the colo-
nization of dental plaque) as an important strategy
in preventing VAP. Despite these recommendations,
limited evidence exists to guide nurses oral hygiene
practice in the general ICU population.
Most available evidence has been developed for
oncology and cardiothoracic patients, and it is not
apparent whether these guidelines are applicable to
general intensive care patients. The omission of oral
care in the ventilation bundle of the Institute for
Healthcare Improvement challenges the recognition
of the relationship between oral care and the devel-
opment of VAP. The American Association of Critical-
Care Nurses recently released a practice alert
5
that
supports the importance of oral care in influencing
outcomes in critically ill patients.
Clearly, fundamental nursing practices such as
hand hygiene,
2,6
semirecumbent positioning of
patients,
2,7,8
subglottal suctioning,
8-12
and reducing
colonization of dental plaque by respiratory
pathogens
4,13,14
play a critical role in minimizing the
incidence of VAP. Nurses admit that these elementary
procedures are often relegated to a lower priority in
the high-pressure, highly technologi-
cal critical care environment. Such
anecdotal reports are further sub-
stantiated by Grap et al,
15
who
found that a sample of 77 health -
care providers perceived oral hygiene
as less important than other unspec-
ified nursing practices to patients
well-being. Therefore, if nurses are
to appreciate the relationship
between dental plaque and its colo-
nization with respiratory pathogens
potentially leading to VAP, they
must have a clear understanding of
the complex characteristics of the oral cavity.
The normal flora of the oral cavity may include
up to 350 different bacterial species,
16
with tenden-
cies for groups of bacteria to colonize different sur-
faces in the mouth. For example, Streptococcus mutans,
Streptococcus sanguis, Actinomyces viscosus, and Bac-
teroides gingivalis mainly colonize the teeth; Strepto-
coccus salivarius mainly colonizes the dorsal aspect
of the tongue; and Streptococcus mitis is found on
both buccal and tooth surfaces.
16
Because of a num-
ber of processes, however, critically ill patients lose a
protective substance called fibronectin from the tooth
surface. Loss of fibronectin reduces the host defense
mechanism mediated by reticuloendothelial cells.
17
This reduction in turn results in an environment
A
lthough nurses recognize that oral hygiene is an integral part of care in intensive
care units (ICUs), the relationship between oral hygiene and the reduction of
oropharyngeal colonization with pathogenic organisms is less recognized. The
vulnerability of ICU patients to nosocomial infections underscores the impor-
tance of examining interventions and strategies to improve patients outcomes.
Ventilator-associated pneumonia (VAP) is a leading cause of death due to nosocomial infec-
tion in ICUs.
1
VAP occurs in 9% to 28% of patients treated with mechanical ventilation, and
mortality rates for VAP are from 24% to 50%. These figures may be higher in immunocom-
promised patients and when the pneumonia is caused by multiresistant pathogens.
1
Although
the relationship between oral care and prevention of VAP is difficult to substantiate directly,
oral hygiene is considered an important strategy in combination with a range of other activi-
ties, such as subglottal suctioning, for improving clinical outcomes.
2
About the Authors
Angela M. Berry is a clinical nurse consultant in intensive
care services at Westmead Hospital and a doctoral can-
didate in nursing at the University of Western Sydney,
Australia. Patricia M. Davidson is professor of cardiovas-
cular and chronic care in the School of Nursing and
Midwifery, Curtin University of Technology, Australia.
Janet Masters is a clinical nurse educator in the high-
dependency unit at Mt Druitt Hospital in Western Sydney,
Australia. Kaye Rolls is a clinical nurse consultant in the
NSWHealth Intensive Care Coordination and Monitoring
Unit and a master of nursing candidate at the University
of Sydney, Australia.
Corresponding author: Angela Berry, Intensive Care Unit,
Westmead Hospital, Darcy Rd, Westmead NSW 2145,
Australia (e-mail: angela_berry@wsahs.nsw.gov.au).
www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2007, Volume 16, No. 6 553
Although use of
an oral hygiene
program is
recommended,
evidence to guide
specific oral
care practices
is limited.
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Both experimental and nonexperimental study
designs were included in the review. Because of the
scarceness of review material on ICU patients receiv-
ing mechanical ventilation, articles that focused on
specific oral care tools or solutions for the seriously
ill also were included in the review.
This review considered studies that included
patients in ICUs who were intubated and receiving
mechanical ventilation. Also included were studies
that proposed a link between oral hygiene and sys-
temic diseases. The interventions of interest were
those designed to affect dental plaque specifically
and oral hygiene in general. The types of outcome
measures considered were general and specific indi-
cators of oral health:
Microbial counts
Plaque indices
Oral assessment scores
Validation of tools used in the provision of
oral care
Articles were excluded if the study sample con-
sisted of healthy participants or the study was done
in a setting other than a critical care environment
(eg, oncology).
Articles published from 1985 to 2006 in English
and indexed in the following databases were searched:
CINAHL, MEDLINE, Joanna Briggs Institute,
Cochrane Library, EMBASE, DARE, and the World
Wide Web search engine, Google. Key search terms
used in the review were oral hygiene, oral hygiene
practices, oral care, mouth care, mouth hygiene, intubated,
mechanically ventilated, intensive care, and critical care.
This search strategy was verified by a health librarian.
Full copies of articles considered to meet the
inclusion criteria (on the basis of their title, abstract,
and subject descriptors) were obtained for data syn-
thesis. Articles identified through reference lists and
bibliographic searches were considered for data col-
lection depending on the titles. Articles were inde-
pendently selected according to prespecified inclusion
criteria by 3 reviewers, each with a minimum of a
masters degree and certification in critical care. Dis-
crepancies in the reviewers selections were resolved
at meetings between the reviewers before the
selected articles were included.
Until recently, one system used to grade levels
of evidence was based on work by the US Agency
for Healthcare Research and Quality. Because of the
increasing awareness of the limitations of that system,
however, the classification structure was revised by
the Scottish Intercollegiate Guidelines Network.
Therefore, the rating method used for categorization
of levels of evidence found in this review was based
on the revised system (Tables 1 and 2).
20
conducive to the attachment of organisms such as
Pseudomonas aeruginosa to buccal and pharyngeal
epithelial cells.
17
The proliferation of organisms
depends to a large extent on their ability to attach to
a surface in the mouth. Bacteria that attach to the
tooth surface gradually coalesce to produce a
biofilm, and after further development lead to the
formation of dental plaque, which is occupied by a
diverse microcosm of organisms.
16
In summary, addressing the formation of dental
plaque and its continued existence by optimizing
oral hygiene in critically ill patients is an important
strategy for minimizing VAP.
Objectives
The goals of this review were to evaluate peer-
reviewed publications to determine the best available
evidence for providing oral care to ICU patients
receiving mechanical ventilation and to document a
research agenda to improve patients outcomes.
Method
Approaches used to review the scientific litera-
ture range from a purposeful, systematic evaluation
of rigorous studies to subjective
overviews of descriptive articles.
18(p53)
Well-conducted systematic reviews
can result in 3 major outcomes. First,
increased power can be obtained by
combining the effects of a number of
smaller studies on the same topic
when homogeneity allows meta-
analysis. Second, systematic reviews
to some extent enable the comparison
of effects of studies with different
designs.
18(p53)
Finally, a prospective
and systematic review allows synthe-
sis of the data and should assist in
providing quality current evidence to
guide clinical practice.
19
Formulation of the review ques-
tion requires extensive background research to
enable an informed outcome. The question must
accurately reflect the extent of the issue to be
reviewed. Therefore, a comprehensive approach,
including a wide-ranging search of the literature
together with consultation with experts, including
nurses, in the field of dental health and critical
care resulted in the following review question:
With respect to intensive care patients receiving
mechanical ventilation, what is the best method
for providing oral hygiene that will result in a
reduction of colonization of dental plaque with
respiratory pathogens?
554 AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2007, Volume 16, No. 6 www.ajcconline.org
Development of
evidence-based
guidelines is
limited by the
small number
of randomized
controlled trials
and the variabil-
ity of interven-
tions studied.
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Results
Although we found a number of references for
the provision of oral hygiene in the management of
oncology and other medical patients, most articles
related to critical care were review articles. For the
prospective randomized control trials we found,
meta-analysis could not be used to synthesize the
results because of variations in the methods of these
studies. For example, in some studies, the populations
assessed differed, and for those studies in which the
populations were the same, the interventions were
often dissimilar. These limitations were recognized in
a recent meta-analysis on the use of chlorhexidine
and the incidence of nosocomial pneumonia.
21
Using the classification system developed by the
Scottish Intercollegiate Guidelines Network, we
reviewed 11 prospective controlled trials,
3,4,13,14,22-28
20 observational studies,
15,29-47
and 24 descriptive
studies.
21,48-70
The 11 articles on prospective controlled
trials are presented in Table 3. Summary tables of the
observational studies (Table 4) and descriptive papers
(Table 5) are available only on the American Journal
of Critical Care Web site (http://www.ajcconline.org)
in the full-text view of this article.
Discussion
The information available for developing
evidence-based guidelines is limited by the small
number of randomized controlled studies and the
heterogeneity of oral hygiene solutions, tools, and
techniques. These limitations are compounded by a
lack of reliable outcome measures to determine the
effectiveness of the oral hygiene interventions. This
lack of rigorous, quality studies markedly limits the
weight of evidence presented and affects recommen-
dations for practice. Despite these limitations, how-
ever, it is important to favor judgments regarding
health benefits and reduction of harm over any pos-
sible cost considerations.
71
This literature review
therefore is summarized as methodological issues,
oral hygiene solutions and equipment, and oral
health assessment strategies.
Methodological Issues
Electronic and hand searches do not completely
reflect the extent of research outcomes. For example,
trials reported at conferences are more likely than
trials published in journals to contain negative reports.
In addition, more positive than negative results tend
to be reported in the literature. This failure to publish
more studies with negative outcomes is due more to
authors lack of inclination to submit such manu-
scripts than to the unwillingness of editors to accept
such manuscripts.
72
Furthermore, many studies not
published in English may not be included in the
most commonly used searches.
73(p43)
These limitations
lead to a risk for systematic reviews to yield a less-
balanced analysis
18(p53)
and may therefore affect the
recommendations resulting from the reviews.
www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2007, Volume 16, No. 6 555
A
B
C
D
No recommendation,
unresolved issue
At least 1 meta-analysis, systematic review, or RCT
rated as 1++ and directly applicable to the target
population or
A systematic review of RCTs or a body of evidence
consisting principally of studies rated as 1+
directly applicable to the target population and
demonstrating overall consistency of results
A body of evidence including studies rated as 2++
directly applicable to the target population and
demonstrating overall consistency of results or
Extrapolated evidence from studies rated as 1++
or 1+
A body of evidence including studies rated as 2+
directly applicable to the target population and
demonstrating overall consistency of results or
Extrapolated evidence from studies rated as 2++
Evidence level 3 or 4 or
Extrapolated evidence from studies rated as 2+
Practices for which insufcient evidence or no
consensus exists about efcacy
Abbreviation: RCT, randomized controlled trial.
Adapted from Harbour and Miller,
20
with permission.
Grade Description
Table 1
Guide to the levels of evidence
1++
1+
1-
2++
2+
2-
3
4
High-quality meta-analyses, systematic reviews of RCTs, or RCTs
with a very low risk of bias
Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs
with a low risk of bias
Meta-analyses, systematic reviews of RCTs, or RCTs with a high
risk of bias
High-quality systematic reviews of case-control or cohort studies
or high-quality case-control or cohort studies with a very low risk
of confounding, bias, or chance and a high probability that the
relationship is causal
Well-conducted case-control or cohort studies with a low risk of
confounding, bias, or chance and a moderate probability that
the relationship is causal
Case-control or cohort studies with a high risk of confounding, bias,
or chance and a signicant risk that the relationship is not causal
Nonanalytic studies such as case reports, case series
Expert opinion
Abbreviation: RCTs, randomized controlled trials.
Adapted from Harbour and Miller,
20
with permission.
Level Therapy/prevention
Table 2
Grades of recommendations
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ple, some participants remained in the study after
extubation, thereby resulting in a mix of intubated
and extubated patients with vastly different accessi-
bility for the provision of oral hygiene. The extu-
bated patients were able to eat and drink fluids,
13
yet no allowance was made for the stimulation of
When we reviewed the 11 prospective con-
trolled trials, a number of methodological issues
became evident. First, the samples were taken from
a range of critically ill patients. Some studies were
limited to cardiac surgical patients, and even within
these studies further variances occurred. For exam-
556 AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2007, Volume 16, No. 6 www.ajcconline.org
Table 3
Prospective controlled trials
Koeman et al,
22
2006
Mori et al,
23
2006
Fourrier et al,
13
2005
Grap et al,
14
2004
Taylor-Piliae et al,
24
2004
Houston et al,
3
2002
Yates,
25
2002
Fourrier et al,
26
2000
DeRiso et al,
4
1996
Holberton et al,
27
1996
Liwu,
28
1990
PRCT
Level of evidence: 1+
Nonrandomized trial with
historical controls
Level of evidence: 2-
PRCT
Level of evidence: 1+
PCT
Level of evidence: 1-
PCT
Level of evidence: 1-
PRCT
Level of evidence: 1+
PCT
Level of evidence: 2-
PCT
Level of evidence: 1-
PRCT
Level of evidence: 1-
PCT
Level of evidence: 2-
PCT
Level of evidence: 2
385
General ICUs
1666 ICU patients
228 ICU patients
34
19
561
cardiac surgery
patients
22
60
353
cardiac surgery
patients
47 ICU patients
40 ICU patients
Chlorhexidine, chlorhexidine and colistin, placebo
Signicant risk of bias: the control group received no reported
oral hygiene except application of petroleum jelly
Preintervention group received no oral care
Intervention consisted of toothbrush, oral assessment score,
povidone-iodine swab, 300 mL weakly acidic water for rinsing
Signicant risk of bias: the control group received no oral hygiene
2 treatment groups: chlorhexidine 0.2% gel vs placebo gel applied
3 times a day
Signicant risk of bias: control group received no oral hygiene,
and toothbrush was not allowed; inclusion criteria included
mechanical ventilation but patients remained in the study after
extubation and were able to eat and drink
No allowance was made for the stimulation of saliva and its
effects during mastication
2 treatment groups: chlorhexidine 0.12% by spray or swab
Risk of bias: control group received unreported type of usual care
Treatment group: toothbrush and toothpaste
Control: metal forceps with cotton wool soaked in thymol
Small sample size reduced proposed causal effect
Chlorhexidine 0.12% rinse compared with Listerine rinse
No mention of tooth brushing; further study required before
results can be adopted in broader ICU population
Test group: nurses received comprehensive oral care training and
used toothbrushes, salt, soda, oss, and sage product (not
described)
Control group: followed unit routine and used sage product
(neither routine nor product described)
Small sample size reduced proposed causal effect
Chlorhexidine gel 0.2% dental plaque decontamination 3 times
daily, compared with bicarbonate solution rinse 4 times daily
followed by oropharyngeal suctioning
No mention of use of toothbrush
Extubated patients could eat/drink, yet no allowance was made
for the stimulation of saliva and its effects during mastication
Compared effectiveness of chlorhexidine 0.12% mouth rinse with
alcohol-based placebo in reducing the incidence of VAP
Compared tap water, normal saline, and 1:1 solution of saline and
hydrogen peroxide
Questionable use of hospital tap water as an oral rinse because of
its reputation for contamination
Compared Ultrafresh solution/swab stick with saline/swab stick
Because of the small sample, risk that relationship is not causal
Abbreviations: ICU, intensive care unit; PCT, prospective controlled trial; PRCT, prospective randomized controlled trial; VAP, ventilator-associated pneumonia.
Source Type of trial No. of participants Method
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saliva during mastication and the subsequent pro-
duction of immune substances. Examples include
substances such as immunoglobulin A, which
obstructs microbial adherence in the oral cavity,
and lactoferrin, which inhibits bacterial infection.
16
These important considerations may have influ-
enced a studys outcome. In their 2005 study, Four-
rier et al
13
also did not permit the use of a tooth-
brush in the protocol, so in effect the control group
received only a neutral gel for the provision of oral
care. It is not surprising, therefore, that the trial
group had a reduced colonization of dental plaque
www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2007, Volume 16, No. 6 557
Reduction in daily risk of VAP in both treatment groups but no difference
in hours of mechanical ventilation, length of stay in ICU, or ICU survival
Incidence of VAP signicantly lower in treatment group
No signicant difference in hours of mechanical ventilation or length of
stay in ICU
Day 10 cultures of dental plaque that showed growth were less common
in the treated group
Ability to reduce incidence of respiratory infections due to multiresistant
bacteria was not signicant
Reduction in oral culture and Clinical Pulmonary Infection Score in treat-
ment group compared with control group
VAP developed in 1 control and 3 study group participants
Oropharyngeal colonization increased 25% in control vs 10% in study
group
VAP reduced by 52% in chlorhexidine group overall and 71% lower in the
chlorhexidine group intubated >24 hours
No statistical difference between groups in Clinical Pulmonary Infection
Score, oral assessment scores, mucosal plaque scores, or inoculum of
plaque
Reduced plaque colonization in the treatment group on days 5-7
Nosocomial infection rate signicantly reduced in the treatment group
with a trend to a reduction of mortality, length of stay, and duration of
mechanical ventilation
Incidence of VAP was 4.6% in the chlorhexidine group and 13% in the
control group
Reduction in mortality was 5.5% in the chlorhexidine group and 1% in the
control group
Statistical analysis was not reported
Patients tolerated tap water best and then saline
Solution of peroxide and saline was not tolerated
No difference between worst scores between both groups
Swab sticks were ineffective for removing oral debris
Large-scale multicenter trial on the efcacy of oral care
for VAP prevention
Further study to determine if combined dental plaque,
oropharyngeal, and salivary decontamination will
decrease VAP in ICU
Use of chlorhexidine early after intubation or before
intubation may reduce incidence of VAP
No recommendations
Limitation of study size acknowledged
Chlorhexidine is worth considering for patients under-
going cardiovascular surgery
Extremely cost-effective compared with 1 case of VAP
Oral care, including oral assessment, is a risk reduction
technique to prevent further infection in hospitalized
patients
A double-blind placebo-controlled study must be done
to conrm these results
Chlorhexidine is an inexpensive and effective agent for
reducing VAP in patients undergoing heart surgery
Larger study required
Further research needed to determine impact of endo-
tracheal tubes on oral mucosa and to evaluate effec-
tiveness of mouth care agents
Results Recommendations/comments
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tion in the ICU.
13
Also, significant cost savings and
decreased mortality may be apparent for such
patients.
4
Further research is required to determine
the frequency of use of chlorhexidine and the rela-
tionship between chlorhexidine use and reduction in
the incidence of VAP in the broader ICU population.
Recommendation: B
Sodium bicarbonate mouth rinse is a clean-
ing agent that can dissolve mucus and loosen oral
debris.
78
This rinse was used as a control substance
in a study by Fourrier et al,
26
who compared it with
a chlorhexidine gel. Although the frequency of col-
onization of plaque on day 5 was higher in the
sodium bicarbonate group, by day 10 no significant
difference could be detected between groups. To
date, no reports of results of randomized controlled
studies that support the use of sodium bicarbonate
over any other mouth rinse in critical care patients
have been published.
Recommendation: Unresolved issue
Houston et al
3
used the essential oil mouth
rinse Listerine (Pfizer, New York, New York) as a
control when testing the effect of chlorhexidine
mouth rinse. Other than that study, essential oils
remain untested in ICU patients. Houston et al did
not find any significant difference between chlorhexi-
dine and Listerine with regard to cultures of sputum
samples from postoperative cardiac patients with
growth of microorganisms.
Recommendation: Unresolved issue
Hydrogen peroxide mouth rinse has been
used untested for many years in ICU patients.
Although their study was excluded from this review
because it included healthy participants, Tombes
and Gallucci
79
found significant mucosal abnormal-
ities in patients treated with hydrogen peroxide
mouth rinse. Holberton et al
27
reported that some
ICU patients found hydrogen peroxide mouth rinse
distasteful and refused to use it. The effectiveness of
foam sticks impregnated with hydrogen peroxide
also has not been rigorously tested for the provision
of oral hygiene in critically ill patients.
Recommendation: Unresolved issue
Physiological salt solution (normal saline),
because of its tendency to cause drying, has limited
use as a mouth rinse in critical care settings.
80
In
fact, in a small study
27
of 47 participants, the partic-
ipants did not tolerate the use of physiological salt
solution as a mouth rinse.
Recommendation: Unresolved issue
at day 10; one could argue that any form of oral
hygiene is likely to produce a better result than
none at all.
A number of other researchers
3,4,14,22,26,27
also
did not mention use of a tooth-
brush in their protocols. Liwu,
28
on
the other hand, mentioned the use
of swab sticks and reported that
they were ineffective in removing
debris between the teeth and gum
borders.
The protocol used by DeRiso et
al
4
included a mint-flavored alcohol
and water-based mouth rinse as the
control versus a 0.12% chlorhexidine
rinse. Although the placebo contained
less than one-third the alcohol con-
tent of the chlorhexidine, the antisep-
tic properties of alcohol may have
had an additional therapeutic effect.
In the protocols of 2 studies,
27,47
hospital tap water was included as an
oral rinse. Because hospital tap water
is a source of nosocomial infections,
74,75
its use as an oral rinse in critically ill
patients is questionable.
Finally, the protocols of 3 studies
25(p174),27,28
included systematic oral assessment, but we were
unable to ascertain whether the frequency of assess-
ments and outcomes measures were similar in the
studies or how these related to the oral hygiene pro-
vided to the study participants.
Oral Hygiene Solutions and Equipment
A range of oral rinse solutions and equipment
are discussed in the literature, and
these data and recommendations are
briefly summarized here.
Chlorhexidine gluconate
mouthwash is an antiplaque agent
with potent antimicrobial activity
that, without causing increased resist-
ance of oral bacteria, is effective at low
concentrations.
76
Chlorhexidine glu-
conate mouth rinse or gel has been
used in a number of clinical tri-
als,
3,4,14,22,26,77
primarily in cardiac sur-
gery patients, to improve gingival
health and to treat oral infections.
Chlorhexidine mouth spray or rinse
appears to be effective in reducing
oral colonization of gram-negative
bacteria and subsequent respiratory infections in car-
diac surgical patients receiving mechanical ventila-
558 AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2007, Volume 16, No. 6 www.ajcconline.org
Although
chlorhexidine
reduces respira-
tory infections
in cardiac
surgery patients,
its effect on ven-
tilator-associated
pneumonia in the
broader ICU
population is
unknown.
No significant
evidence sup-
ports the use
of sodium bicar-
bonate or hydro-
gen peroxide
impregnated
sticks for use with
the critically ill.
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Tap water, although readily available and
free, can be a source of nosocomial infections in
hospitals.
74,75
Recommendation: Not recommended for use as a
mouth rinse in critically ill patients
Sterile water used as a mouth rinse is cost-
effective, but such use has not been rigorously tested.
Recommendation: Unresolved issue
Use of a toothbrush and toothpaste is recom-
mended by several authors.
40,57(pp1-4),81
Furthermore, a
toothbrush with toothpaste is more effective than
foam swabs for the removal of plaque.
82
Griffiths et
al
57(pp1-4)
recommend a very small, soft-bristled tooth-
brush because it can reach the most posterior aspects
of the mouth. Such a toothbrush is also useful for
cleaning the tongue and gums in edentulous patients.
For any patient who has sensitive gums, gentle
cleaning is of paramount importance. Although
bacteremia after tooth brushing in healthy persons
is rare,
83
care is advised when this procedure is used
in immunocompromised critically ill patients. Fur-
thermore, because toothbrushes must be treated as
potential sources of contamination, thorough clean-
ing and protected storage of the brushes after each
use should be mandatory.
Recommendation: D
Foam and cotton swabs generally are not
effective for removing debris and plaque.
82,84,85
Even
so, Ransier et al
85
suggest the use of foam swabs soaked
in chlorhexidine if a toothbrush is considered inap-
propriate. Roberts
86
raises concern, although it is not
substantiated in the literature, about the possible
detachment of foam from the swab stick during the
provision of oral hygiene in less compliant patients.
Recommendation: Unresolved issue
Although swabs impregnated with lemon and
glycerol have been used for some time, their value
has been questioned, and such swabs may actually
have deleterious effects such as xerostomia and
decalcifying of tooth enamel.
41,84,87
Recommendation: Unresolved issue
Suction devices. No published reports describe
a comparison between the various suction devices
used to provide oral hygiene. Devices such as suction
foam swabs and rigid suction tools (eg, Yankauer
device) are only generally effective for clearing
secretions from the oral cavity. However, because
the importance of removing secretions from the
subglottic area is well known,
10,11,88,89
use of a flexible
suction catheter when rinsing the mouth after oral
hygiene is essential.
Recommendation: D
Oral Health Assessment Strategies
Reliable and valid assessment tools are needed
to document nurses assessments of the oral cavity
as well as the effectiveness of oral hygiene interven-
tions. The paucity of data related to solutions and
techniques is paralleled by the limited data available
on assessment tools. The oral assessment tool used
by Fitch et al
41
reportedly included assessment of
several oral components, such as dental plaque,
inflammation, salivary flow, bleeding, candidiasis,
purulent matter, calculus, staining, and caries. When
scores were compared between dental hygienists
and nurses trained in the use of the tool in a study
41
of 60 adult ICU patients, the correlations were posi-
tive. This result indicated that nurses who used this
tool were adept at assessing changes in the oral cav-
ities of their patients.
Recommendation: D
Implications for Clinical Research
and Practice
Although colonization of den-
tal plaque with respiratory
pathogens correlates with occur-
rence of pneumonia,
13
protocols
based on research studies for best
practice in providing oral care in
ICUs are rare.
51
Therefore, in the
absence of evidence-based guide-
lines to direct best practice, critical
care nurses often perform oral
hygiene according to their individ-
ual preferences and historical pat-
terns.
51
These preferences are often
based on a combination of avail-
ability of one product over another
and the nurses experience and
knowledge underpinning this prac-
tice. Clearly, these are important
issues to address, especially because of the relation-
ship between poor oral hygiene and the incidence
of VAP.
46,90
Finally, although nurses self-reporting of oral
hygiene practices has been examined in 3 stud-
ies,
15,30,31
the studies do not fully explore nurses per-
ceptions of the importance of these practices. That
is, nurses regularly undertake a number of routine
practices in the care of critically ill patients, but little
evidence is available to measure nurses sense of the
importance of these practices and how optimizing
www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2007, Volume 16, No. 6 559
Without evi-
dence-based
guidelines to
direct best prac-
tice, critical care
nurses often per-
form oral hygiene
according to their
individual prefer-
ences and histori-
cal patterns.
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improving the quality of care
Assessment of nurses attitudes and beliefs
about the importance and possible benefits of oral
hygiene in the ICU
FINANCIAL DISCLOSURES
None reported.
REFERENCES
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the structure of these practices may affect the overall
health of ICU patients. For example, reported state-
ments such as Mouthcare is very important to my
care unless [theres] no time for it
15
imply that
oral hygiene is not considered part of the essential
care required by ICU patients. It would be notewor-
thy, for instance, if this same statement was made
with regard to administration of medications, yet oral
hygiene is an important strategy not only for patients
comfort but for improving clinical outcomes.
It is therefore vital that adequately powered,
randomized, controlled clinical trials be undertaken
to develop and evaluate oral hygiene practices for
critically ill patients. These data are essential to opti-
mize oral hygiene practices and inform evidence-
based practice. The potential for oral care guidelines
to contribute to reducing the incidence of VAP is an
important area for ongoing research in the ICU.
The following conclusions can be drawn from
this systematic literature review:
Apart from the possible use of chlorhexidine
mouth rinse in cardiothoracic intensive care patients,
high-level evidence that could inform clinical practice
regarding oral hygiene in ICUs is limited. That is, meta-
analysis is hindered by the absence of
standardized processes such as use of
solutions and oral hygiene tools and
by the lack of outcome measures
such as validated oral assessment
scales relative to ICUs.
Only a few small studies have
addressed nurses perceptions of the
importance of oral hygiene practices
and the barriers that prevent or strate-
gies that facilitate adherence to evi-
dence-based practice guidelines.
Because oral care may con-
tribute to improved clinical outcomes, further
research is warranted for establishing best-practice
guidelines. Also, the provision of protocols and the
capacity for monitoring and evaluating these
processes could improve clinical outcomes.
These limited data make oral care a fertile area
for ongoing nursing research. Topics for potential
further research include the following:
Well-designed, adequately powered clinical
trials to determine the most effective techniques for
oral hygiene for reducing the incidence of dental
plaque, with respect to the most effective use of
solutions, equipment, and procedure for adults
receiving mechanical ventilation
Development of standardized oral assessment
techniques and tools not only for research but also
for assessing patients, evaluating practice, and
560 AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2007, Volume 16, No. 6 www.ajcconline.org
Limited high-level
evidence exists
to inform clinical
practice regard-
ing oral hygiene
in the intensive
care setting.
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SEE ALSO
To learn more about oral hygiene and other methods
for preventing ventilator-associated pneumonia in the
intensive care unit, visit http://ccn.aacnjournals.org
and read the article by Augustyn and colleagues,
Ventilator-Associated Pneumonia: Risk Factors and
Prevention (Critical Care Nurse, August 2007).
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Name Member #
Address
City State ZIP
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Payment by: KVisa KM/C KAMEX KCheck
Card # Expiration Date
Signature
CE Test Test ID A071606: Systematic Literature Review of Oral Hygiene Practices for Intensive Care Patients Receiving Mechanical Ventila-
tion. Learning objectives: 1. Describe important strategies to decrease ventilator-associated pneumonia. 2. Compare different studies that examine various
oral hygiene methods. 3. Analyze the results of different studies of oral hygiene practices.
Program evaluation
Yes No
Objective 1 was met K K
Objective 2 was met K K
Objective 3 was met K K
Content was relevant to my
nursing practice K K
My expectations were met K K
This method of CE is effective
for this content K K
The level of difficulty of this test was:
Keasy Kmedium Kdifficult
To complete this program,
it took me hours/minutes.
Test ID: A071606 Contact hours: 1.5 Form expires: November 1, 2009. Test Answers: Mark only one box for your answer to each question. You may photocopy this form.
1. Based on their literature review, the authors state that recommendations
for practice are af fected by which of the following?
a. Lack of rigorous quality studies
b. An overabundance of studies
c. Homogeneity of oral hygiene solutions
d. Evidence of reliable outcomes
2. Which of the following can result in a less balanced analysis of
systematic reviews?
a. Foreign studies, which are an integral part of research literature
b. The increasing number of studies with negative outcomes
c. The small number of published studies with positive outcomes
d. The lack of published studies with negative outcomes
3. Which of the following oral hygiene solutions would be recommended
based on the literature review described in this study?
a. Sodium bicarbonate
b. Hydrogen peroxide
c. Chlorhexidine gluconate
d. Tap water
4. According to the literature review in this article, which oral hygiene
equipment would be best?
a. Toothbrush with toothpaste
b. Foam swabs
c. Lemon/glycerin swabs
d. Swabs with rigid suction device
5. Which of the following decreases the incidence of ventilator-associated
pneumonia?
a. Reduction of dental plaque
b. Bacterial colonization
c. Oral hygiene
d. Loss of fibronectin
6. According to this article, critical care nurses perceived which of the
following as a low priority?
a. Bathing
b. Oral care
c. Medication administration
d. Range of motion exercises
7. Which of the following was a limitation in this studys literature review?
a. Too many studies were not in the critical care area
b. Most articles in critical care were scientific control studies
c. Variations in the methods of the studies
d. Inconsistencies in the medical and critical care literature
8. What were the limitations in the literature review as related to oral
hygiene assessment strategies?
a. No verified assessment tools
b. Incongruity of nursing training on tools
c. Lack of data
d. Nursing reluctance about using tool
9. Which of the following inf luences oral hygiene practices by nurses?
a. Evidence-based research
b. Standing protocols
c. Physicians orders
d. Individual preferences
10. According to the authors, which of the following would be an important
area for ongoing research in critical care?
a. Oral care as related to the incidence of sepsis
b. Ventilator-associated pneumonia and oral hygiene practices
c. Analysis of various oral hygiene solutions
d. Nursing perception of oral care
11. In reference to oral care research, the authors suggest which of the
following?
a. Controlled randomized studies of oral care equipment
b. Establishing best practice guidelines
c. Developing oral assessment tools for nurses
d. Comparing critical care nursing research with medical surgical nursing research
12. Which of the following methods was chosen to review literature
pertinent to oral hygiene for this study?
a. Systematic evaluation
b. Subjective overview of descriptive articles
c. Meta-analysis
d. Objective observation
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