Intensive and Critical Care Nursing (2006) 22, 318—328

REVIEW

Beyond comfort: Oral hygiene as a critical

nursing activity in the intensive care unit
Angela M. Berry a,∗, Patricia M. Davidson b

aIntensive Care Services, Westmead Hospital, University of Western Sydney, Sydney, Australia
bNursing Research Unit, School of Nursing, Family & Community Health,
University of Western Sydney & Sydney West Area Health Service, Australia

Accepted 6 April 2006

KEYWORDS Summary
Oral hygiene; Background: The role of oral hygiene in maintaining the health and well being of
Research; patients in the intensive care unit (ICU) is indisputable. This importance is not
Knowledge reflected in the body of research related to ICU practice. While a number of studies
have examined oral hygiene practices in oncological patients there is significantly
less attention devoted to these practices in the critically ill.
Aim: This paper has two discrete yet interrelated aims. Firstly, in relation to cur-
rent available evidence and based on a sound knowledge of oral physiology, identify
barriers to effective oral hygiene and subsequent effectiveness of the most com-
monly used and recommended methods of providing oral hygiene in the critically ill
population. Secondly, informed by the critical review, identify recommendations for
practice and future intervention studies.
Findings: To date, there is no definitive evidence to determine the most appropri-
ate method of oral hygiene including the use of beneficial mouth rinses. Barriers
identified in this review to providing optimal hygiene include: (1) mechanical bar-
riers and equipment issues, (2) perceptions of the importance of mouth care and
empathy with patient discomfort by nurses, (3) altered patient sensory perception
and discomfort and (4) difficulties in patient communication. In spite of these chal-
lenges opportunities for collaborative research and increasing expertise in nurse
researchers creates a climate to derive solutions to these factors.
Conclusions: It is clearly evident from this review of oral hygiene practices in inten-
sive care that the need for ongoing research is of paramount importance. ICU nurses
undeniably require rigorous research studies in order to inform their practice in the
provision of oral hygiene for critically ill patients.
Crown Copyright © 2006 Published by Elsevier Ltd. All rights reserved.

∗ Correspondence to: Intensive Care Unit, Westmead Hospital, Darcy Road, Westmead, NSW 2145, Australia. Tel.: +61 2 9845 6065;

fax: +61 2 9845 9090.

E-mail address: angela berry@wsahs.nsw.gov.au (A.M. Berry).

0964-3397/$ — see front matter. Crown Copyright © 2006 Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.iccn.2006.04.003
Oral hygiene as a critical nursing activity 319

Contents

1. Beyond comfort: oral hygiene as a critical nursing activity ................................................ 319

2. Prevention strategies for VAP ............................................................................. 319
3. Ecology of the mouth ..................................................................................... 320
4. Dental plaque............................................................................................. 320
5. Stomatitis and gingivitis .................................................................................. 320
6. The tongue and saliva..................................................................................... 320
7. Challenges to oral care in critical care .................................................................... 321
8. Mechanical barriers ....................................................................................... 321
9. Equipment ................................................................................................ 321
10. Perceptions of importance and patient discomfort by the nurse........................................... 324
11. Patient perception and discomfort issues ................................................................. 325
12. Communication ........................................................................................... 325
13. Summary: implications for nursing practice, research and policies ........................................ 325
14. Education issues influencing the provision of oral hygiene in the critically ill.............................. 325
15. Conclusion ................................................................................................ 326
Acknowledgements........................................................................................ 326
References ................................................................................................ 326

1. Beyond comfort: oral hygiene as a
critical nursing activity
Almost without exception, the experience of a
fresh, clean mouth following cleaning one’s teeth
is universal. This is an activity that most indi-
viduals undertake, a number of times every day
and generally speaking, would not be satisfied
with simply passing a cotton swab stick over their
teeth. Why then, should we as nurses, do any less
for our patients? In addition to issues relating to
patient comfort, there is increasing evidence in
the literature to suggest a link between coloniza-
tion of dental plaque with respiratory pathogens
and ventilator-associated pneumonia (VAP) (Four-
rier et al., 1998; Scannapieco, 1996). In fact,
after urinary tract infections, the second most
common nosocomial infection but the leading
cause of death, is ventilator-associated pneumo-
nia. Ventilator-associated pneumonia is a com-
mon and highly morbid condition in critically ill
patients, occurring in 9—68% of patients treated
with mechanical ventilation. Mortality rates range
from 33 to 71% and can be higher in specific high-risk
patients such as those patients who are immuno-
compromised (Eggimann and Pittet, 2001; Fleming
et al., 2001; Koeman et al., 2001; Fagon, 2002;
Apostolopoulou et al., 2003). This paper has two
discrete yet interrelated aims. Firstly, to critically
examine key factors in providing oral hygiene in
ICU; review the most commonly used and recom-
mended methods of providing oral hygiene in the
critically ill population within the context of avail-
able evidence; and specifically identify barriers to
effective oral hygiene. Secondly, informed by the
critical review identify recommendations for prac-
tice and future intervention studies.
While this paper is not a formal systematic
review of the literature for oral hygiene practices
in relation to the prevention of VAP, it does rep-
resent the synthesis of data and information from
an eclectic range of sources. These sources include
textbooks, pharmacological information and the
peer reviewed literature. Articles published from
1985 to 2005 in English and indexed in the fol-
lowing databases were searched: CINAHL, Med-
line, Joanna Briggs Institute, Cochrane Library,
Embase, DARE, Web search—–Google Search Engine.
The MeSH keywords were ‘‘oral hygiene’’, ‘‘oral
hygiene practices’’, ‘‘oral care’’, ‘‘mouth care’’,
‘‘mouth hygiene’’, ‘‘intubated’’, ‘‘mechanically
ventilated’’, ‘‘intensive care’’ and ‘‘critical care’’.
The reference lists of published materials were also
hand searched for additional information. The aim
was to identify all relevant randomised controlled
trials, descriptive studies as well as discussion doc-
uments. Only seven prospective, randomized con-
trolled trials relating to the specialty of intensive
care (De Riso et al., 1996; Fourrier et al., 2000;
Grap et al., 2004; Holberton et al., 1996; Houston,
2002; Liwu, 1990; Nelsey, 1986) were identified.
These studies varied in rigour from 561 to 4 sub-
jects.
2. Prevention strategies for VAP
Key factors proposed in preventing VAP include
selective digestive tract decontamination (Collard
et al., 2003) semi-recumbent patient positioning
320
(Drakulovic et al., 1999; Orozco-Levi et al., 1995)
subglottal suctioning (Kollef, 1999; Mahul et al.,
1992; Valles et al., 1995) oscillating beds (Choi and
Nelson, 1992) and reduction in dental plaque colo-
nization with respiratory pathogens (Fourrier et al.,
1998; Scannapieco et al., 1992). Clearly fundamen-
tal nursing practices play a critical role in minimis-
ing VAP. Anecdotally it is often these ‘‘basic’’ skills
that become subsumed in the high pressure, highly
technological critical care environment. Therefore,
in order to appreciate the relationship between
dental plaque and its colonization with respiratory
pathogens potentially leading to VAP, it is impor-
tant to have a clear understanding of the intricate
features of the oral cavity. These key factors and
information related to the ‘state of the science’
are described below.
3. Ecology of the mouth
Most oral bacteria are considered to be part of the
normal flora and may consist of up to 350 different
species (Bagg et al., 1999). Various organisms pos-
sess a tendency to colonize different surfaces in the
mouth. For example, Streptococcus mutans, Strep-
tococcus sanguis, Actinomyces vicosus and Bac-
teroides gingivalis mainly colonize the teeth while
Streptococcus salivarius mainly colonize the dor-
sal tongue. Lastly, Streptococcus mitis is found on
both buccal and tooth surfaces (Gibbons, 1989).
However, in critically ill patients, increased levels
of proteases in their oral secretions removes from
their epithelial cell surface, a substance called
fibronectin. A glycoprotein, fibronectin is present
on cell surfaces and acts as a reticuloendothelial
mediated host defense mechanism. This depletion
of fibronectin exposes receptors to the attachment
of organisms such as Pseudomonas aeruginosa to
buccal and pharyngeal epithelial cells (Gibbons,
1989). Since adhesion to a surface in the mouth
is important for the continued existence and pro-
liferation of organisms, bacteria which attach to
the tooth surface gradually coalesce to produce a
biofilm and after further development, lead to the
formation of dental plaque (Bagg et al., 1999).
4. Dental plaque
Dental plaque is the accumulation mainly of oral
microorganisms and their products. These adhere
tenaciously to the teeth and are not readily
dislodged (Spraycar, 1995). When dental plaque
matures and becomes calcified, it contains a
A.M. Berry, P.M. Davidson
diverse microcosm of organisms. Calculus con-
tains a rough, porous surface which allows bac-
teria and bacterial toxins to be absorbed and
stored. This accumulation of potentially harmful
substances poses a serious risk to the individual
(Bagg et al., 1999). Bacteria and their products can-
not only invade a compromised periodontal pocket
and cause systemic disease but bacteria such as
P. gingivalis and A. actinomycetemcomitans, have
the ability to directly invade undamaged tissues.
In these instances, the individual is then at risk of
developing a bacteraemia and organ dysfunction.
In fact Fowler et al. (2001) state that periodon-
titis poses up to a seven-fold increase in risk for
premature birth and a two-fold increase risk for car-
diovascular disease.
5. Stomatitis and gingivitis
Stomatitis is a painful inflammation of the mucous
membrane of the mouth (Spraycar, 1995). The
development of stomatitis increases the risk of
pathogen translocation and can result in a num-
ber of adverse consequences such as sepsis and
subsequent multiple organ failure (Holmstrup et
al., 2003). Gingivitis is inflammation of the gingiva
(gum) in a response to bacterial plaque on adjacent
teeth. It is characterized by erythema, oedema and
fibrous enlargement of the gingiva (Spraycar, 1995).
There are a number of common forms of gingivitis,
some of which are associated with systemic disease,
e.g. leukaemia, some are steroid induced but the
most common is plaque-related gingivitis (Bagg et
al., 1999). If the intubated patient does not receive
effective oral hygiene, then bacterial plaque with
deposits of S. mutans and Actinomyces viscosus
develops on the teeth within 72 h. This is fol-
lowed by emerging gingivitis and a subsequent shift
from primarily Streptococcus and Actinomyces spp.
to increasing numbers of aerobic Gram-negative
bacilli (Estes and Meduri, 1995).
6. The tongue and saliva
The dorsal posterior aspect of the tongue contains
layers of debris not removed during swallowing and
despite indications that the tongue harbours mil-
lions of organisms (Christensen, 1998) cleaning is
not generally undertaken as a routine, by most
people.
Saliva is a mixed fluid secreted predominantly
from the parotid, submandibular and sublingual
glands and to a lesser extent from the minor salivary
Oral hygiene as a critical nursing activity 321

glands and the gingival crevicular spaces (Bagg et

al., 1999). Saliva has a number of important func-
tions such as washing food debris and unattached
microorganisms from the mouth. It neutralizes
acids produced by bacteria on tooth surfaces and
because it contains calcium and phosphorus, works
together with fluoride in the remineralization of
tooth surfaces. In addition saliva contains a num-
ber of immune substances such as immunoglobu-
lin A, which obstructs microbial adherence in the
oral cavity and lactoferrin which inhibits bacte-
rial infection in the healthy individual (Bagg et al.,
1999).
As a consequence of the protective nature of
saliva, Dennesen et al. (2003) propose that in
the intensive care patient, a severe reduction
of salivary flow and subsequent xerostomia and
mucositis may result in oropharyngeal colonization
with respiratory pathogens and the progression to
ventilator-associated pneumonia. During the day, in
Figure 1 Ventilated patient.
the healthy individual, unstimulated salivary flow
ranges from 0.25 to 0.35 mL/min while stimulated
flow may reach quantities of 4—6 mL/min. Severe other device securing the endotracheal tube (ETT)
xerostomia is defined as an unstimulated salivary in place presents a further obstacle when attempt-
flow of less than 0.1 mL/min (Dennesen, 2003). Con- ing to clean the patient’s mouth.
ditions in the critically ill which impacts on salivary
flow include fever, diarrhoea, burns, reduced fluid
intake and a number of medications such as opiates, 9. Equipment
anticholinergics and diuretics which contribute to
xerostomia (Dennesen, 2003). To add to the barriers mentioned above, nurses gen-
erally have inadequate tools to use for mouth care.
The following is an overview of the most commonly
7. Challenges to oral care in used tools currently in use and, on the basis of the
critical care available evidence, recommendations for practice
are:
Although oral hygiene is a fundamental practice 1. Toothbrush. As the picture in Fig. 2 demon-
nurses provide for their patients, undertaking this strates, normal adult size toothbrushes, due
practice in the ICU can be challenging for a range to their size, are often difficult to maneuver
of reasons. Key barriers related to achieving opti- around the obstacles in the mouth. These tooth-
mal oral hygiene can be classified as mechanical
obstacles, perceptions of importance and patient
discomfort by the nurse, patient perception and
discomfort issues and finally, communication bar-
riers. These issues are discussed in greater depth
below.

8. Mechanical barriers
Perhaps most significantly, mechanical obstructions
challenge efficient and effective oral hygiene. The
mouth of the ventilated intensive care patient is
crowded with devices such as endotracheal and oral
gastric tubes and occasionally a temperature probe.
In addition as Fig. 1 demonstrates, the tape or Figure 2 Adult size toothbrush.
322
brushes are rarely able to reach the most pos-
terior aspects of the patient’s mouth and unless
very soft-bristled, are in all likelihood unsuit-
able for cleaning the tongue, or gums in eden-
tulous patients. Thus, edentulous patients are
subjected to cleaning with a swab stick only.
However, the preferred tool for cleaning the
teeth remains the toothbrush (Franklin et al.,
2000; Griffiths et al., 2000; Pearson, 1996).
In fact a study by Pearson and Hutton (2002)
demonstrated a substantial benefit in the use of
toothbrushes over foam swabs for the removal
of dental plaque. However, the normal adult
toothbrush poses a significant problem when
attempting to access the mouth of the intubated
patient. Needless to say, in order to maintain
the patient’s airway, extreme caution must be
exercised when providing oral hygiene in this
situation. While some authors (O’Reilly, 2003)
advise, for ease of access, cleaning the teeth
during change of the endotracheal tube (ETT)
tapes, this practice is not recommended by oth-
ers (Hatlestad, 2005). The risk of accidental
dislodgment of the ETT during normal change
of tapes is significant but if one attempts to
brush the patient’s teeth while the ETT is not
secure, the risk of accidental removal is vastly
increased. Therefore, it is advisable to use a
soft-bristled ‘‘baby’’ toothbrush which not only
provides greater access to all regions of the
mouth but can also be used to gently brush the
tongue and in edentulous patients, the gums
(Bowsher et al., 1999). There are however some
limitations associated with the use of a tooth-
brush such as in those patients who have bleed-
ing gums and/or low platelet counts. In these
instances, regardless of the tool used, extreme
care should be taken when cleaning the patient’s
mouth.
2. Cotton/foam sticks. Other tools commonly
available for mouth care include cotton and
foam swabs both of which have been reported
Figure 3 Cotton/foam swabsticks.
A.M. Berry, P.M. Davidson
to have very little plaque debriding ability.
Although research has generally been done
on healthy subjects, the toothbrush has been
demonstrated to be more effective than cot-
ton/foam swabs in removing debris and plaque
(Rawlins, 2001). While foam and cotton swabs
sticks (Fig. 3), have been found to be ineffective
in removing oral debris (Buglass, 1995) another
study (Ransier et al., 1995) advocated the use
of foam brushes soaked in chlorhexidine when
toothbrushes could not be used. Others how-
ever (Roberts, 2000), have raised some concern
regarding the health and safety risk of possible
detachment of the foam should a patient bite
the foam stick. To date, there appears to be no
evidence of this incident occurring, reported in
the literature.
3. Toothpaste. While toothpaste is not considered
crucial for plaque elimination (Kite, 1995) the
effect of topical applications of fluoride have
long been considered essential in the preven-
tion of decay. This remineralising effect is due
to the bacteriostatic and antienzymatic actions
of fluoride (Bagg et al., 1999). However, the use
of a non-foaming toothpaste is preferable to the
standard toothpaste when the aim is to improve
patient oral comfort and reduce halitosis. This is
because a non-foaming (sodium lauryl sulphate
free) toothpaste is more readily rinsed clear
of the mouth. This attribute of a non-foaming
toothpaste is clinically important as any tooth-
paste residue may have a drying effect on the
mucosa.
4. Mouth rinses. Although few have been tested
in the critical care population, the mouth
rinses most commonly reported in the litera-
ture, include chlorhexidine, sodium bicarbon-
ate, hydrogen peroxide, sodium chloride, water,
povidone-iodine, thymol and lemon and glyc-
erine. While some countries require a medical
prescription for the use of the following prod-
ucts, others allow use by nurse instigation. A full
Oral hygiene as a critical nursing activity
description of each mouth rinse is provided as
follows:
• Chlorhexidine 0.1—0.2%: This is recom-
mended as the most effective antiplaque
agent (Bagg et al., 1999; Eldridge et al.,
1998; Fourrier, 2000; Grap, 2004; Jones,
2000; Houston, 2002). Chlorhexidine, a pos-
itively charged molecule, works by binding
to negatively charged sites on tooth enamel
and mucosal cells. This action results in
a reduction of microbial adherence to the
tooth and mucosal surfaces. Chlorhexidine
also binds with bacterial cell-wall structures,
altering the cell osmotic equilibrium. This
allows leakage of potassium and phospho-
rous and as a result, damages the cell con-
tents (Bagg et al., 1999). Chlorhexidine has
an inhibitory effect against Gram-positive and
Gram-negative organisms and yeast (Brinor et
al., 1994). Lastly, chlorhexidine, by its slow
release properties, maintains an antimicrobial
activity up to 12 h. In a study by Elworthy
(1996), the degree of substantivity or pres-
ence of action, demonstrated chlorhexidine
to be the most effective substance in both
outcome and length of action when compared
with cetylpyridinium chloride (CPC) rinse and
two types of toothpaste.
• Sodium bicarbonate mouthwash 1%: Sodium
bicarbonate mouthrinse is a cleaning agent
reported to reduce the viscosity of oral
mucus, therefore enhancing the removal of
oral debris (Carl et al., 1999; Dodd et al.,
2000). If the commercially available solution
is not used, care must be taken to ensure
correct dilution when preparing the solution
for use as a mouthrinse. This is important
because if the recommended concentration
is not adhered to, the possibility of oral
mucosa irritation may result. Sodium bicar-
bonate has a similar efficacy as hydrogen
peroxide in the treatment of mucositis due
to radiation (Dudjak, 1987). But in contrast
to hydrogen peroxide, in the recommended
strength, sodium bicarbonate does not leave
an unpleasant aftertaste. However, to date,
there are no reported randomized controlled
studies to support its use over any other
mouthrinse, in the critical care population.
• Hydrogen peroxide: Hydrogen peroxide, a
member of a group of related molecules
termed reactive oxygen species, is a clear,
colourless, odour-free solution. It is com-
pletely soluble in water and gives an aciditic
solution, the degree of which is dependent on
its dilution. For example in a 1% solution the
323
pH range is between 5 and 6 (Walsh, 2000).
Hydrogen peroxide has been used for more
than 70 years as a mouthrinse and is still cur-
rently widely used in both professional dental
and self-administered products. Since hydro-
gen peroxide must be diluted before use,
there is a risk of mucosal irritation if the incor-
rect strength is used. In fact a study by Tombes
and Gallucci (1993) where 35 normal subjects
were randomly assigned to rinse with either
normal saline, 1/4 strength hydrogen perox-
ide or 1/2 strength hydrogen peroxide, in both
hydrogen peroxide groups significant mucosal
abnormalities were observed. Although the
study was not blinded, there were also numer-
ous subjective complaints of discomfort in the
hydrogen peroxide groups. There are how-
ever, hydrogen peroxide impregnated foam
sticks available but again the use of these has
not been subjected to rigorous randomized
controlled trials. In addition, given the neg-
ative reports of the use of hydrogen peroxide
in healthy subjects and the proven attributes
of toothbrushes compared with foam sticks
(Pearson, 1996), the use of hydrogen peroxide
impregnated foam sticks cannot be recom-
mended for use in the critically ill population.
• Sodium chloride: While there is some evi-
dence that the use of sodium chloride mouth
rinses can promote healing of oral mucosal
lesions, because of its tendency to cause dry-
ing, its routine use as a mouth rinse is limited
in the critical care setting (Bowsher, 1999).
• Water: The use of water to provide moisture
to and remove debris from, the oral cavity
of intensive care patients may be underesti-
mated. Water, a safe, ubiquitous solution can
be used in combination with a small, soft-
bristled toothbrush to clean the teeth and
gums or as a sole agent to rinse and remoisten
the oral cavity to minimize xerostomia. How-
ever, it is important to note that hospital tap-
water has been identified as a serious source
of waterborne nosocomial infections, notably
those attributed to Pseudomonas (Anaissie et
al., 2002). Therefore, the use of small bot-
tles of sterile water, clearly marked with date
and time of first accessing the solution and
sealed between use to minimize contamina-
tion, may be a cost effective mouth rinse for
use in intensive care patients.
• Povidone-iodine: This solution has been used
for many years in general wound care includ-
ing post-operative wounds of the oral cav-
ity (Chandu, 2002). Garrouste-Orgeas et al.
(1997) compared povidone-iodine disinfec-
324 A.M. Berry, P.M. Davidson

tion of the oropharyngeal cavity of inten-

sive care patients with sucralfate or H2 -
receptor antagonists in a study of ventilator-
associated pneumonia. They determined that
microorganisms related to infections, were
more evident in the oropharyngeal samples
than the gastric samples. Therefore, although
povidone-iodine may be useful in treating
mucosal wounds following surgery, since it
does not have an anti-plaque effect and pro-
longed use may result in significant amount
being absorbed (Chandu et al., 2002), it is of Figure 4 Monojet syringe.
questionable value as a regular mouthrinse for
intensive care patients.
• Other agents: Thymol solution is said to be a
lip skin flakes. Both vaseline and lanolin have an
refreshing agent but is devoid of any clean-
occlusive effect which reduces transepidermal
ing or disinfecting properties (Roberts, 2000).
water loss.
Its use therefore as a mouth rinse for the
6. Dental syringes. Special syringes with a curved
intensive care patient is clearly questionable.
nozzle, such as the Monojet (Fig. 4), are very
Lemon and glycerol swabs, although said to
useful for applying mouth rinses to intubated
initially stimulate salivary flow, may exhaust
patients. The unique attributes of these syringes
this mechanism in excessive use and thereby
allow relative ease of access to all areas of the
result in xerostomia (Miller and Kearney,
mouth including the difficult to reach posterior
2001). Also due to their acidic and decalcify-
region.
ing effect on tooth enamel, these swabs are no
7. Suction devices. The use of the flexible suc-
longer generally used for the provision of oral
tion catheter is advocated as it can reach the
care in intensive care patients (Fitch et al.,
subglottic area unlike the less flexible yankeur
1999).
suction tool. This device is essential for remov-
ing secretions pooled above the ETT cuff. This
5. Saliva replacement and lip moisturizes. Sali-
should be done prior to attending mouth care
vary substitutes are important agents in mois-
and again to remove rinsing solutions accumu-
turizing the mouth of the xerostomic patient.
lated above the cuff and/or in the mouth, during
Since some of these products lack the antibac-
the provision of oral care.
terial or immunological attributes of natural
8. Tongue cleaning. While there are a number of
saliva (Buglass, 1995) it is therefore important to
commercially available implements for cleaning
select those which proclaim to contain the sali-
the tongue, ranging from plastic or metal tools
vary enzymes lactoferrin and lysozyme, essen-
to small brushes to scrape or rake the tongue,
tial for boosting the natural immune process
the use of a small, soft-bristled toothbrush used
(Bagg et al., 1999). Also unless meticulous care
while cleaning the teeth may also be used to
is taken, the lips of intubated patients are at
clean the tongue. This procedure involves a for-
extreme risk of becoming dry and cracked. This
ward raking motion along the posterior region
risk is the result of an inability of the patient
of the tongue and is important in cleaning the
to naturally remoisten the lips by passing the
tongue of debris. This process would also min-
tongue around the lip surface, and because the
imize growth of papillae which would normally
lips are often subjected to pressure from the ETT
be abraded during mastication (Danser et al.,
and its securing device. It is therefore imper-
2003).
ative to maintain the integrity of the lips to
ensure patient comfort as well as to prevent a
site for harbouring bacteria (Xavier, 2000). The
use of petroleum jelly (vaseline) as a so-called 10. Perceptions of importance and
lip moisturizer has been advocated and used for patient discomfort by the nurse
many years (Fitch et al., 1999; O’Reilly, 2003).
Lanolin is another commonly used product to Unfortunately, emphasis on the provision of oral
prevent lip dehydration. It is a wool fat deriva- hygiene is allocated a low priority in a number of
tive, which contains emollient properties. That nursing undergraduate programs (Hayes and Jones,
is, it is thought to fill the spaces between dry 1995; Kite and Pearson, 1995) and although con-
Oral hygiene as a critical nursing activity
sidered to be a basic nursing practice, it is at risk
of being relegated a low priority when caring for
a complex intensive care patient (Hixson et al.,
1998; Jones et al., 2004). Maintaining patient safety
and comfort also impact on decisions with regard
to the frequency and type of mouth care adminis-
tered by intensive care nurses. That is, some nurses
have expressed the following concerns related to
oral care: dislodging the ETT, failing to remove all
toothpaste and risk of aspiration of the mouth rinse
used when providing oral hygiene (Kite and Pearson,
1995).
11. Patient perception and discomfort
issues
In addition to mechanical barriers, individual
patient factors may also pose a challenge to the
provision of mouth care. The patient may be fear-
ful of all procedures to which he/she is subjected
in ICU and certainly there is evidence of these per-
ception derangements reported in the literature
(Roberts, 2005). This may include a procedure such
as mouth care which is perceived by the nurse as
being very basic and completely painless. In addi-
tion, due to the administration of sedatives and
analgesics, almost all ICU patients experience some
degree of confusion at some time during their stay
in ICU (Rundshagen et al., 2002; Roberts et al.,
2005). This altered perception of reality experi-
enced by the patient may confound attempts by the
nurse to thoroughly clean the patient’s mouth and
therefore result in a rudimentary swabbing of the
patient’s teeth and gums with only a cotton or foam
swab stick. If the patient is in pain, there may be a
reluctance to comply with the attempted practice
of mouth care, once more resulting in inadequate
care being provided.
12. Communication
Due to the possible confusion mentioned above
and the presence of the ETT, ICU patients have
a reduced capacity to communicate. This lack of
ability to speak can often be the source of gross
irritation and frustration for the patient which may
also lead to lack of compliance with oral hygiene.
Lastly, in the case of a language barrier, the patient
may have no or very little understanding of the pro-
posed procedure and through fear or inability to
comply with instructions such as ‘‘please open your
mouth’’, again create an obstacle to optimal mouth
care.
325
13. Summary: implications for nursing
practice, research and policies
As discussed above neglected or insufficient oral
hygiene will lead to an accumulation of bacterial
plaque and the possibility of gingival inflammation.
This in turn results in elevated levels of enzymes
with the potential to modify local tissue surfaces
and therefore affecting the types of bacteria which
may colonize the mouth (Gibbons, 1989). Dental
plaque will then act as a reservoir for both aerobic
and anaerobic pathogens (Chaste and Fagon, 2002).
The tongue is normally abraded to some extent,
during swallowing of food by the healthy individual
(Christensen, 1998). As intubated patients do not
eat food they lack this mechanism for cleaning the
tongue. Therefore, gentle brushing of the tongue
with a soft-bristled toothbrush is recommended
(Brecx et al., 1989). As can be seen above multi-
ple mouth rinses and methods exist to provide oral
hygiene however there is still no clear consensus
on how frequently mouth care should be attended.
Some authors advocate brushing the teeth of intu-
bated patients twice a day and moistening the
mouth every 2 h (Barnason et al., 1998) while others
advise the use of oral assessment scores to deter-
mine mouth care regimes (Day, 1993).
14. Education issues influencing the
provision of oral hygiene in the
critically ill
Together with the routine bed-bath, the provision
of oral hygiene is viewed as a basic nursing func-
tion. The review above illustrates that oral hygiene
is not only far more than provision of basic comfort
care but also represents a critical factor in pre-
venting VAP. This shortfall in the prioritization of
oral hygiene in the high pressure and highly tech-
nological critical care environment is possibly due
to a deficiency in oral health knowledge or a lack of
appreciation of its importance by registered nurses
(Adams, 1996; Grap, 2003). In a recent study (Furr
et al., 2004), length of ICU experience did not cor-
relate to quality of mouth care provided. Of inter-
est, adequate time for procedures and the view that
mouth care was an unpleasant task were signifi-
cant factors. This appears somewhat incongruous
given that one would expect that with experience,
nurses would acquire the ability to prioritize nurs-
ing practices and also to become to some extent,
desensitized to the perceived unpleasantness of
cleaning another person’s mouth. To compound this
knowledge deficit, standardised protocols, based
326
on empirical evidence, for oral hygiene in the care
of the critically ill, are exceedingly lacking. Con-
sequently in the absence of evidence based guide-
lines to direct best practice, critical care nurses
frequently perform oral hygiene according to their
individual rationales (Moss, 2004). This preference
is commonly based on a combination of availabil-
ity of one product over another and the nurse’s
experience and knowledge underpinning this
practice.
Therefore, if a change in practice, supported by
best evidence, is to be accomplished it is impor-
tant to have a clear understanding of what is
meant by evidence based practice. According to
Courtney (2005) evidence based practice is the
‘‘conscientious, explicit and judicious use of cur-
rent best evidence in making decisions about the
care of individual patients. It involves the inte-
gration of: clinical expertise with the best avail-
able clinical evidence from systematic research and
patient values to ensure the delivery of the most
appropriate and cost effective care.’’ Furthermore
this evidence must be adapted to the individual and
his/her health environment (Cook, 2003). Clearly,
there is a need for ICU clinicians to collabora-
tively develop evidence based guidelines to inform
best practice in the ICU. The quality and efficacy
of these guidelines is dependent on high quality
research. It is also likely that significant educational
activities are necessary to stress the importance
of this task to clinicians in ICU. Finally, guidelines
should be evaluated for effect, value and usage,
and reviewed and modified regularly to incorporate
new evidence (Courtney, 2005).
15. Conclusion
While it is recognised that the discussion above is
not based on a systematic review of the literature
it does help to underscore the importance of high
level evidence to inform this critical nursing task.
The paucity of randomised controlled clinical trial
evidence identifies this as an important area for
nursing research in order to inform evidence based
practice. Significantly, guideline development for
oral hygiene in ventilated ICU patients should be
extensively explored and based on sound evidence.
There should be a clear statement as to its purpose,
scope and limitations. The therapeutic preferences
should be outlined and the reasons for their inclu-
sion listed. The expected outcome of the guide-
line should be specified and finally, the guideline
should be peer reviewed and recommendations pro-
posed via consensus. The legitimacy and strength
of the guideline will be increased if this process is
A.M. Berry, P.M. Davidson
followed. Following implementation, the effective-
ness of the guideline should be evaluated as part of
a quality improvement process and updated as new
evidence emerges.
Finally it is clearly evident from this review of
oral hygiene practices in intensive care that the
need for research is of paramount importance. ICU
nurses undeniably require rigorous research studies
in order to inform their practice in the provision of
that essential care, oral hygiene, for their critically
ill patients.
Acknowledgements
Many thanks to Rudi Gottl and Jacqueline Richards
for the photographic work.
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