REVISIÓN DE LA LITERATURA
CUIDADO DE LA SALUD BUCAL EN PACIENTES
DE LAS UNIDADES DE CUIDADOS INTENSIVOS
Introducción: la higiene bucal es considerada una necesidad básica para
proteger la salud y el bienestar de la población, con mayor énfasis en los
pacientes bajo soporte de cuidados intensivos.
Objetivo: revisar brevemente la literatura sobre el papel efectivo de equipos
profesionales bien capacitados en la realización del cuidado bucal en
pacientes atendidos en la Unidad de Cuidados Intensivos.
Métodos: artículo de revisión cientíca, tomando como fuente de información
la literatura actual publicada en la base de datos PubMed entre 2004 y
2024, incluyendo revisiones sistemáticas, metaanálisis y estudios de revisión
relacionados con los procedimientos de cuidado bucal y sus relaciones con
los resultados de pacientes críticos bajo el riesgo de infección.
Resultados: Se analizaron 28 artículos, con datos de pacientes niños o adultos
de diversos continentes que necesitaron ventilación mecánica, alimentación
enteral o parenteral, o algún procedimiento invasivo que favoreciera
las infecciones hospitalarias, principalmente las neumonías. La literatura
revisada describió con mayor frecuencia la falta o insuciencia de atención
especializada para la cavidad bucal de pacientes con autonomía muy
limitada durante las internaciones.
Conclusión: en conjunto, existe la necesidad de que los odontólogos del equipo
hospitalario realicen personalmente, además de capacitar en el servicio
al personal de enfermería y sus asistentes, para llevar a cabo los métodos
correctos para la higiene bucal diaria del paciente, con el mejoramiento de
la salud general. cuidado de la salud y evitando el empeoramiento durante
el período de hospitalización.
29
Resumen
Palabras clave: Odontología, Unidad de cuidados intensivos, Higiene bucal, Educación del personal.
Forma de citar este artículo: Chiozini L,
Santos VM. ORAL HEALTH CARE IN
PATIENTS OF THE INTENSIVE CARE
UNITS. Med Vozandes. 2024; 35 (1): 29 - 34
1 Hospital Dentistry. Brasília-DF – Brazil.
2 Catholic University of Brasília, Adjunct-professor of
Internal Medicine. Brasília-DF – Brazil
3 Armed Forces Hospital. Brasília-DF – Brazil.
ORCID ID:
Larissa Chiozini Bittencourt
orcid.org/0009-0000-0270-5117
Vitorino Modesto dos Santos
orcid.org/0000-0002-7033-6074
Este artículo está bajo una
licencia de Creative Com-
mons de tipo Reconocimien-
to – No comercial – Sin obras
derivadas 4.0 International.
DOI: 10.48018/RMVv35i13
*Corresponding author:Vitorino Modesto dos Santos
E-mail: vitorinomodesto@gmail.com
Received: 24 – Feb – 2024
Accepted: 30 – Apr – 2024
Publish: 01 – Jul – 2024
Article history
Conflict of interest: The authors have full freedom
of manuscript preparation, and there were no potential
conicts of interest.
Financial disclosure: The authors have no nancial
relationships relevant to this article to disclose.
CRediT – Contributor Roles Taxonomy:
Conceptualización, Curación de datos, Análisis formal,
Investigación, Metodología, Visualización, Redacción –
borrador original, Redacción – revisión y edición: LCB
– LAVMDS.
Larissa Chiozini Bittencourt 1, Vitorino Modesto dos Santos2,3*
Revista Médica Vozandes
Volumen 35, Número 1, 2024
30
INTRODUCTION
The oral hygiene (OH) is considered a basic need to protect
the health and well-being of the population, especially for the
patients under intensive care support; and the use of toothbrushes
and topical antimicrobials improves the OH of compromised
patients reducing the occurrence of hospital infections including
the pneumonia (1-28). Numerous protocols have been described,
which differ in diverse countries, and their insertions depend on
the standards and type of assistance offered in each location,
highlighting the economic impact on the type of treatment used
for each patient (28). Based on the type of OH care that the patient
receives during the hospital admission, the multidisciplinary work
of professionals from specialized teams and the availability
Although the effectiveness of preventing complications and
conrmed benets, they are not adopted in some hospitals
simply by performing the general common OH (13). Due to lack
of constant correct hygiene procedures, the cases of oral biolm
related to ventilator-associated pneumonia (VAP) have been
more frequent, and associated with ominous complications that
could be avoided by the trained professionals in OH (25). Very
important is highlighting the OH being carried out
in accordance with well-dened standards and
specications, to get real markers of satisfaction
and positive result (7); and that the success of
hygienic procedures depends on continuous
repetitions (27). During the recent pandemic,
one concern was about a dysbiotic oral ora
colonize the lower respiratory tract causing
VAP in ICU patients without effective support of
OH (8). Studies in high-income countries showed
effectiveness of brushing through more complex
means and around a routine outside the Intensive
Care Unit (ICU), but also used there, carrying out
the procedures with the brushes and topical
solutions (18). Other studies indicate that even less
sophisticated protocols for the OH can guide to
signicant clinical improvements in addition to
resulting in budgetary advantages (23).
CUIDADO DE LA SALUD BUCAL EN PACIENTES DE
LAS UNIDADES DE CUIDADOS INTENSIVOS Chiozini Bittencourt L, et al.
Introduction: oral hygiene is considered a basic need to protect the health
and well-being of the population, with more emphasis for patients under
intensive care support.
Objective: shortly review the literature about effective role of well-trained
professional teams while performing oral care in patients managed in the
Intensive Care Unity.
Methods: scientic review article, taking as a source of information the
current literature published in the PubMed database between 2004 and
2024 including, systematic reviews, meta-analysis, and review studies related
with the buccal care procedures, and their relationships with the outcomes
of critical ill patients under the infection risks.
Results: 28 articles were analyzed, with data of children or adult patients
of diverse continents who needed mechanical ventilation, enteral or
parenteral feeding, or some invasive procedure favoring the hospital
acquired infections, mainly the pneumonias. The reviewed literature most
frequently described the lack or insufcient specialized care for the oral
cavity of patient with very limited autonomy during hospitalizations.
Conclusion: as a whole, there is a need for the dental specialists in the
hospital team to personally perform, besides to train in service the nurse
staffs and their assistants to carry on the correct methods for the patient daily
buccal hygiene, with improvement of general health care and avoiding the
worsening during the hospitalization period.
Abstract
ORAL HEALTH CARE IN PATIENTS
OF THE INTENSIVE CARE UNITS
Keywords: Dentistry, Intensive care unit, Oral hygiene, Staff education
Revista Médica Vozandes
Volumen 35, Número 1, 2024
31
REVISIÓN DE LA LITERATURA
OBJECTIVE
The objective was to carry out a brief literature review about
the effective role of well-trained professional teams while
performing OH in patients managed in ICUs.
METHOD
To perform this this work PubMed was used as the research base,
selecting articles written in English and published between May
2004 and January 2024; and utilizing the keywords: dentistry,
intensive care unit, oral hygiene, and staff education.
LITERATURE DATA
A random survey in 102 ICUs of the United States in 2004 with
556 respondents (97% nurses) about the oral care provided,
showed 92% considering the high priority of OH, but staffs did
not follow protocols to reduce the cases of VAP (3). The current
practice is to evaluate measures that can optimize the quality
of care for the hospitalized patients, as the example of
reducing complications, avoiding an increase in the total and
the average length of hospitalization; and regarding to the
oral cavity care there are OH protocols for patients under
mechanical ventilation (MV) (21). Turkish nurses have excelled in
specialized training and practical capacitation for hospital
treatment of OH, resulting in an increased number of excellent
professionals interested in improving, with a reduction of those
who did not search for excellence (17). An Iranian study of 2019
including demographic and clinical data, besides the Beck’s
oral status assessment scale (BOAS) among 138 patients
treated in ICUs revealed disturbances in their lips (14.4%), gums
and oral mucosa (26.1%), tongue (16.6%), teeth (49.3%), and
saliva (34.8%); and only 5.8% presented normal oral condition
(2). The prevalence of buccal lesions was high in patients
without brushing the teeth, and the presence of oral tubes; the
authors emphasized the role of training nursing workers in OH,
in addition of a routine evaluation of patients in ICUs by
specialized dentists (2). In South Korea, a study describes the
differences reported by nurses themselves, which indicate the
need to use the OH modality with specic training techniques,
which is not yet a practical reality. They concluded that there is
a lack of both qualied professionals to provide training and
well-dened consensual protocols to follow (12). Other study
carried out in Jordan showed that well-installed OH protocols
can reduce the incidence of ventilator-associated pneumonia
(VAP), more often in cases of lung disease and in those intubated
for more than 7 days and with open suction system (1). At the
conclusion of that research, the important role of establishing a
more efcient protocol to be followed during all the
management of these patients became clear (1). In the United
States, research was carried out among nurses on the
importance and difference of the specialized integrated OH
services, and the activity was considered of higher priority, and
performed with foam swabs, moisturizers and mouthwashes (3).
This research involved the following parameters: frequency and
type of the provided oral care, the attitudes and beliefs; the
knowledge and training in OH were measured
with the aim to know their effects on the quality of
care and the reduction of VAPs (3) In fact, there is
increasing mortality of patients on mechanical
ventilation (MV) when OH is omitted, while the
VAPs are reduced by following their respective
protocols (4). VAP is a major infection affecting
near 30% of patients on MV, and a preventive
effect of povidone-iodine (PI) among adults
treated in ICUs was reviewed in four studies (5).
Three studies showed PI not statistically decreasing
VAP compared to the placebo; one compared
the effect of PI with chlorhexidine and the
difference was not signicant; two revealed a
decreased ICU stay by PI but not signicant if
compared to placebo; and three showed that PI
had no effect on the mortality in comparison with
placebo (5). The evaluation of tooth brushing OH
to prevent VAP in 657 patients with MV in an ICU,
compared tooth brushing plus chlorhexidine
mouthwash to chlorhexidine or tooth brushing
plus placebo, and the results were similar to the
chlorhexidine cotton wipe (6). In 2013, responses of
questionnaires were evaluated in Switzerland
about protocols for hospital VAP prevention, and
90% reported toothbrush teeth cleaning (75%
three times daily), 97% utilized chlorhexidine, and
systemic antibiotics were never used; the authors
highlighted the lack of standardized protocols to
prevent VAPs in the ICUs (7). A recent study about
the effect of tooth brushing on the oral bacteriota
and health care- associated infection (HAI) in ICU
included 56 adults with COVID-19 and MV of two
groups: one with standard care, other with
extended procedures and tooth brushing (8). The
bacterial samples were obtained within 36 h and
after 7 days of the intubation; there was signicant
dysbiosis and a decrease in the oral bacteriota
diversity, with major pathogenic agents like
Acinetobacter baumannii and Klebsiella
pneumoniae, and the HAI incidence was
elevated most commonly by these two infectious
agents (8) The authors concluded that dysbiotic
oral bacteriota is a main source of respiratory
pathogens, and the OH with tooth brushing can
cause a decrease in the size of this bacteriota
dysbiosis, but without reducing the risk of the HAIs
and mortality in ICUs (8). A Korean study about
the factors inuencing the OH of patients in ICUs
evaluated the current buccal care practice,
besides perceptions, and attitudes of 227 ICU
nurses (9). The answers of respective questionnaire
showed the main factors affecting the attitude
about the role of OH for ICU patients, as the
working experience as nurses and in ICU, besides
the frequency of their oral care practice that
had a statistical signicance (9). The authors
commented on the high interest of the nurses for
OH practice, but training and implementation of
oral care practices for patients in ICU were found
Revista Médica Vozandes
Volumen 35, Número 1, 2024
32
frequent complication among MV patients (16).
The main monitored interventions have been
head-of-bed elevation, semi-recumbent
positioning, sedation and weaning protocols,
prophylaxis of deep venous thrombosis, subglottic
suctioning, OH, hand hygiene, peptic ulcer, and
cuff pressure control (16). Four studies showed a
low VAP reduction, 22 found over 36% of VAP
reduction, 10 revealed a decrease over 65%, and
in 4 the VAP rate was zero or nearly to zero;
adequate endotracheal tube cuff pressure and
subglottic suction favored less VAP (16). A Turkish
study about OH attitudes and practices of 185
ICU nurses was performed in four hospitals
without either consistent oral care protocol or
assessment guidelines (17). The data analysis
revealed that the procedures and the frequency
of OH work, besides solutions and material
resources utilized were different in each hospital;
they authors concluded emphasizing the need
to establish a continuing training of nurses in OH
(17). A study from 2013 to 2017, including 4,103 ICU
patients with MV and orotracheal tube for 48
hours or more, and comparing before (Baseline
Group) and after (Intervention Group) the OH
protocol was performed by a multidisciplinary
team and a dentist (18). The Baseline Group (from
January 2013 to May 2015) had 213 patients,
while the Intervention Group (from June 2015 to
December 2017) had 137 patients; 45 cases
(21.12%) of Baseline Group and 5 cases (3.65%)
of Intervention Group had VAP (18). The mortality
by VAP was 48.89% for the Baseline Group and
20.00% for Intervention Group, with better
outcomes of patients evaluated and treated by
an ICU dentist (18). An Iranian study between 2016
and 2018 evaluated the newly registered ICU
nurse professional competence in OH in three
phases: before, during, and after the care (19). The
major increase of OH care competency due to
repetition occurred in the rst and fourth times of
repetition comparing with subsequent and
previous phases; the demographic variables
predicted up to 19% of changes in skill scores by
repetition (19). The authors concluded that new ICU
nurses get the competency with 6 repetitions (19). A
Colombian study about educational intervention
on nursing staff oral care included 40 nurses and
20 NAs, and data of 171 patients, 70 cared for
after an intervention (20). Daily buccal care
increased from 29.6% to 92.8% after intervention,
the VAPs reduced from 8.9% to 2.8%, and from 9
to 3.5 cases per 1,000 days after the intubation (20).
Although not statistically signicant, the decrease
was clinically relevant for the institution continuing
educational strategies on the OH directed to the
nurse staffs (20). A Brazilian study on the impact of
OH for patients under MV during COVID-19
pandemic concluded that the inclusion of
hospital dentistry in the multidisciplinary team is
insufcient (9). Worthy of note, is a previous Korean review
including 58 studies grouped in three categories, seven of
them evaluating the OH of patients in ICUs, which revealed
the majority of them with poor buccal hygiene and needing
some dentistry treatment (10). Oral care utilizing chlorhexidine
with tooth brushing were recommended in 33 studies, while in
36 studies the dentistry interventions was successful to
prevention of HAIs (10). A self-report survey with 33 questions
related to education and knowledge on buccal diseases,
besides perception of dental specialized education and
practice among ICU nurses and more than a half of those
treating gingivitis, periodontitis, and caries had complete
dental education; the majority of the others did not know oral
diseases (11). The authors stressed the insufcient knowledge of
oral diseases of ICU nurses, the need of dentistry cooperation,
and the lack of practical guidelines about oral care (11). A
descriptive survey of 149 Korean nurses revealed that 40.9% of
them provided oral health care for hospitalized patients in
spite of 89.5% of hospital protocols lack (12). Nurses of the ICU
more likely provided oral health care than those of general
wards (83.9% vs 15.1%); 83.2% of them knew the role of OH for
hospitalized patients, but 36.4% vs 26.0% of them considered
that this care should be provided by the dentistry. The authors
suggested that nurses and dental specialists work
collaboratively (12). Interviews were performed with 11 Chinese
nurse assistants (NAs) of three ICU units, about diverse themes,
including self-perception, frequency, importance, barriers and
challenges (lack of education, training, or support) related to
the oral care activities (13). The OH was scarcely associated
with disease prevention and a priority activity, and main
difculties in the ICU include insufcient education, training,
and due support (13). The authors stressed that OH must be
prioritized in ICUs, and the role of NAs in nursing work better
recognized, with standardized norms and the multidisciplinary
support (13). Studies about preventive OH related to VAPs in
pediatric ICUs (PICUs) were reviewed, including evaluation about
efcacy of colostrum and sodium bicarbonate utilization (14).
Treatments (n = 120) were distributed in groups: 1) colostrum
plus bicarbonate, 2) bicarbonate, and 3) colostrum; the
occurrence of VAPs was respectively 2, 8, and 6, conrming the
effects of bicarbonate and colostrum to prevent VAPs in
newborns (14). Another study among 96 children separated in
two groups, one using chlorhexidine and other a placebo; the
OH was twice daily by toothbrush and an antiseptic gel, and
there was no difference between the groups with respect to
bacterial colonization, mortality rate, ventilator assistance
period, and time of permanence in in the PICU (14). The authors
emphasized that in those patients without pathogenic ora on
Day 0, the utilization of chlorhexidine for the OH was found to
be protective against the VAP (14). Worthy of note were the
results of 15 studies about the utilization of toothbrushing and
chlorhexidine in MV patients with the objective of VAP
prevention; ten among them showed a positive association,
while ve studies did not revealed decreasing in VAP incidence
neither by the isolate nor the combinate toothbrushing with
chlorhexidine (15). The authors highlighted that both toothbrushing
and chlorhexidine may reduce VAPs, but the utilization of
toothbrushing should be regularly long-standing maintained (15).
The systematic review of 38 articles published since 2004 about
VAPs conrmed that this very ominous event remains as a
Revista Médica Vozandes
Volumen 35, Número 1, 2024
CUIDADO DE LA SALUD BUCAL EN PACIENTES DE
LAS UNIDADES DE CUIDADOS INTENSIVOS Chiozini Bittencourt L, et al.
33
REVISIÓN DE LA LITERATURA
important, to better implementation of OH protocols and
research about the procedures and products to get effective
buccal care, reducing the cases of VAP (21). A prospective study
including 220 ICU patients aged from 18 to 65 years, 110 of study
group (S) utilizing chlorhexidine wash, tooth brushing, and
moisturizing gel on gums, buccal mucosa, and lips; and 110 of
control group (C) using only the chlorhexidine (22). The rates of
VAP and mortality were signicantly lower in the group S, oral
care with chlorhexidine mouth wash and adjuvant measures
reduced VAP, and hospital stays; tooth brushing and the
standard OH contribute to prevent the VAP in MV patients (22). A
study was done from June 2004 to May 2005 among MV patients
in ICUs under an oral care protocol including sodium
monourophosphate paste and brush, rinsing with tap water,
and the chlorhexidine solution utilized twice daily at 12-hour
intervals (23). During the preintervention period occurred 24
infections in 4606 ventilator days, while after the utilization of the
oral care protocol, there were 10 infections in 4158 ventilator
days, which resulted in the statistically signicant reduction of
46% in the VAPs (23). The staff compliance with the oral care
protocol in 12-month period averaged 81%; and adoption of
simple low-cost OH procedures in the ICU decreased risks of
VAP (23). An American study included 9 patients with the mean
age of 50 ± 12.9 years and class IV stage D cardiac failure, and
were 22 days in average after the ventricular assist device
placement, receiving dental treatment after the prophylactic
antibiotic therapy and maintenance of anticoagulation with
antiplatelet, or the antithrombin regimen (24) Eight patients had
dental extractions, one of them also had scaling and root
planning of the remaining teeth; the other patient only needed
the scaling and root planning; the authors highlighted the
unremarkable outcomes by utilizing established protocols (24) A
prospective study evaluated if OH with toothbrushing plus
chlorhexidine in gel can reduce the VAPs, the duration of MV
and of hospital stay, and the ICUs mortality rate, comparing to
OH only with chlorhexidine, among 213 hospitalized adults
under MV; that were distributed in control group (n = 108) and
intervention group (n = 105) (25). Toothbrushing plus chlorhexidine
was associated with a lower incidence of VAPs, although not
statistically signicant, but there was a signicant reduction of
the mean time of MV in the toothbrushing group; while the
duration of hospital stays in the ICU as well as the mortality rates
presented with no statistically signicant differences (25).
Ecological effects of selective oral decontamination (SOD) on
multidrug-resistance bacteria (MDRB) acquired by ICU patients
under MV were evaluated over 5 years (26). Differences in the
rates and incidence densities (ID: cases per 1000 patient-days)
of MDRB related to SOD use in the patients, and stratied by
outpatients or inpatients; 5034 patients were included in the
study and 1694 of them did not receive SOD (26). No differences
were found in the ID of MDRB when SOD was utilized, except for
Enterococcus faecium, and Klebsiella pneumoniae; SOD was
associated with lower incidence of VAP and death in ICU, but
not with bacteremias or urinary infections (26). In a hospital of
Istanbul where the intensive treatment was utilized during at
least ve days, a study was carried out evaluating the general
care and oral mucosa protection of the patients with MV,
chronic disturbances, and enteral or parenteral nutrition (27). The
authors concluded that the frequency of OH must be
determined according to the patient’s condition and the
presence of risk factors for oral complications,
requiring the participation of a specialized
professional to diagnose and establish the
duration (27). The comparison between the effects
of 0.2% and 2% chlorhexidine solution to reduce
the oropharyngeal colonization and the VAPs by
means of OH was studied among 114 ICU patients
distributed in two groups, undergoing
oropharyngeal swab cultures (28). There was a
signicant reduction in VAPs and in oropharyngeal
colonization in the group that utilized 2%
chlorhexidine, without difference between
adverse effects (28).
CONCLUSION
It is understood that there is a strong need for the
dental specialist in the hospital environment to
carry out training or perform procedures indicated
in relation to OH, aiming the improvement in
the quality of general health care, avoiding the
worsening of the systemic condition, due to lack
of a specic care for the oral cavity during the
hospitalization, especially in places where the
patient is very limited, such as in ICUs.
Revista Médica Vozandes
Volumen 35, Número 1, 2024
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CUIDADO DE LA SALUD BUCAL EN PACIENTES DE
LAS UNIDADES DE CUIDADOS INTENSIVOS Chiozini Bittencourt L, et al.
Revista Médica Vozandes
Volumen 35, Número 1, 2024
