Risk-Adapted Oral Care Protocols for Critically Ill Patients: Scientific Rationale And Clinical Perspectives

Abstract

Oral deterioration in critical illness is heterogeneous. A cooperative non-intubated patient with preserved salivary flow does not require the same intensity or technique of care as an intubated patient with severe xerostomia, mucosal ulceration, bleeding risk and impaired swallowing. Uniform schedules may therefore result in under-treatment of high-risk patients and unnecessary or unsafe procedures in others. This narrative review develops the scientific rationale for a risk-adapted oral care framework based on systemic stability, airway status, aspiration risk, mucosal integrity, salivary function, dental and prosthetic conditions, and capacity for self-care. The proposed framework links assessment findings to mechanical plaque control, moisturizing care, device-pressure prevention, secretion management, antiseptic use when indicated, documentation and referral. It is presented as a conceptual protocol requiring local adaptation and prospective validation, not as an already proven intervention.

Keywords:

Critical illness, oral care, risk adaptation, oral assessment

References

Scannapieco F.A., Stewart E.M., Mylotte J.M. Colonization of dental plaque by respiratory pathogens in medical intensive care patients. Critical Care Medicine. 1992;20(6):740–745.

Dennesen P., van der Ven A., Vlasveld M. et al. Inadequate salivary flow and poor oral mucosal status in intubated intensive care unit patients. Critical Care Medicine. 2003;31(3):781–786. doi:10.1097/01.CCM.0000053646.04085.29.

El-Solh A.A., Pietrantoni C., Bhat A. et al. Colonization of dental plaques: a reservoir of respiratory pathogens for hospital-acquired pneumonia in institutionalized elders. Chest. 2004;126(5):1575–1582. doi:10.1378/chest.126.5.1575.

Ullman A., Long D., Lewis P. The oral health of critically ill children: an observational cohort study. Journal of Clinical Nursing. 2011;20(21–22):3070–3080. doi:10.1111/j.1365-2702.2011.03797.x.

Saensom D., Merchant A.T., Wara-aswapati N., Ruaisungnoen W., Pitiphat W. Oral health and ventilator-associated pneumonia among critically ill patients: a prospective study. Oral Diseases. 2016;22(7):709–714. doi:10.1111/odi.12535.

de Lacerda Vidal C.F., Vidal A.K.L., Monteiro J.G.M. et al. Impact of oral hygiene involving toothbrushing versus chlorhexidine in the prevention of ventilator-associated pneumonia: a randomized study. BMC Infectious Diseases. 2017;17:112. doi:10.1186/s12879-017-2188-0.

Hua F., Xie H., Worthington H.V. et al. Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia. Cochrane Database of Systematic Reviews. 2020;12:CD008367. doi:10.1002/14651858.CD008367.pub4.

Choi B.K. et al. Risk prediction models for the development of oral-mucosal pressure injuries in intubated patients in the intensive care unit. Journal of Clinical Nursing. 2020. PMID:32800513.

Giuliano K.K., Penoyer D., Middleton A., Baker D. Oral care as prevention for nonventilator hospital-acquired pneumonia: a four-unit cluster randomized study. American Journal of Nursing. 2021;121(6):24–33. doi:10.1097/01.NAJ.0000753468.99321.93.

Dale C.M. et al. Effect of oral chlorhexidine de-adoption and implementation of an oral care bundle on mortality for mechanically ventilated patients. Intensive Care Medicine. 2021.

Klompas M., Branson R., Cawcutt K. et al. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 update. Infection Control & Hospital Epidemiology. 2022;43(6):687–713.

Kökcü Ö.D., Terzi B. Development of an intensive care oral care frequency assessment scale. Nursing in Critical Care. 2022;27:550–558. PMID:32633044.

Lei S., Liu Y., Zhang E. et al. Influence of oral comprehensive nursing intervention on mechanically ventilated patients in ICU: a randomized controlled study. BMC Nursing. 2023;22:293. doi:10.1186/s12912-023-01464-w.

Ehrenzeller S., Klompas M. Association between daily toothbrushing and hospital-acquired pneumonia: a systematic review and meta-analysis. JAMA Internal Medicine. 2024;184(2):131–142. doi:10.1001/jamainternmed.2023.6638.

Lin C.C., Liaw J.J., Li C.H., Chen L.C., Han C.Y. Nurse-led intervention to improve oral mucosal health of intubated patients in the intensive care unit: a prospective study. American Journal of Infection Control. 2024;52(8):900–905. doi:10.1016/j.ajic.2024.01.014.

Çiftçi M.A., Efe Arslan D. Factors affecting the oral health of patients in intensive care units: a prospective observational study. Journal of Research in Nursing. 2024;29(6):483–496. doi:10.1177/17449871241262114.

Yamakita S. et al. Comparative efficacy of various oral hygiene care methods for preventing ventilator-associated pneumonia: a network meta-analysis. 2024. PMID:39671440.

Han J.M., Wagner J., Hedden-Gross A. et al. Interventions to prevent nonventilator hospital-acquired pneumonia: rapid review. Making Healthcare Safer IV. Rockville: Agency for Healthcare Research and Quality; 2025. doi:10.23970/AHRQEPC_MHS4PNEUMONIA.