Oral care practices in intensive care units: A survey of 59 European ICUs

Abstract

To explore the type and frequency of oral care practices in European ICUs and the attitudes, beliefs, and knowledge of health care workers.
An anonymous questionnaire was distributed to representatives of European ICUs. Results were obtained from 59 ICUs (one questionnaire per ICU) in seven countries 91% of respondents were registered nurses.
Of the respondents 77% reported that they had received adequate training on providing oral care; most (93%) also expressed the desire to learn more about oral care. Oral care was perceived to be high priority in mechanically ventilated patients (88%). Cleaning the oral cavity was considered difficult by 68%, and unpleasant as well as difficult by 32%. In 37% of cases respondents felt that despite their efforts oral health worsens over time in intubated patients. Oral care practices are carried out once daily (20%), twice (31%) or three times (37%). Oral care consists principally of mouth washes (88%), mostly performed with chlorhexidine (61%). Foam swabs (22%) and moisture agents (42%) are used less frequently as well as manual toothbrushes (41%) although the literature indicates that these are more effective for thorough cleaning of the oral cavity. Electric toothbrushes were never used.
In European ICUs oral care is considered very important. It is experienced as a task that is difficult to perform, and that does not necessarily succeed in ensuring oral health in patients with prolonged intubation. Oral care consists primarily of mouth washes. The use of toothbrushes should be given more attention.

Full text

Intensive Care Med
DOI 10.1007/s00134-007-0605-3 BRIEF REPORT
Jordi Rello
Despoina Koulenti
Stijn Blot
Rafael Sierra
Emili Diaz
Jan J. De Waele
Antonio Macor
Kemal Agbaht
Alejandro Rodriguez
Oral care practices in intensive care units:
a survey of 59 European ICUs
Received: 18 August 2006
Accepted: 28 February 2007
© Springer-Verlag 2007
Electronic supplementary material
The online version of this article
(doi:10.1007/s00134-007-0605-3) contains
supplementary material, which is available
to authorized users.
This research was supported in part by
PIO5/2410 FIS of the Spanish government
and the Catalonian Research Fund
(2005/SGR920), and by CibeRes
(CB06/06/0036).
J. Rello (u) · E. Diaz · A. Rodriguez
Joan XXIII University Hospital, Critical
Care Department,
Mallafrè Guasch 4, 43007 Tarragona, Spain
e-mail: jrello.hj23.ics@gencat.net
Fax: +34-977-295878
D. Koulenti
Athens University, Department of Critical
Care Medicine, Attikon University Hospital,
Medical School,
Athens, Greece
S. Blot · J. J. De Waele
Ghent University Hospital, Intensive Care
Department,
Ghent, Belgium
R. Sierra
Puerta del Mar University Hospital,
Intensive Care Unit,
Cadiz, Spain
A. Macor
A. di Savoia Hospital, ASL3, Preven,
Rischio Infettivo,
Turin, Italy
K. Agbaht
Hacettepe University, Intensive Care Unit,
Ankara, Turkey
Abstract Objective: To explore
the type and frequency of oral care
practices in European ICUs and the
attitudes, beliefs, and knowledge
of health care workers. Design:
An anonymous questionnaire was
distributed to representatives of Eu-
ropean ICUs. Results were obtained
from 59 ICUs (one questionnaire
per ICU) in seven countries 91% of
respondents were registered nurses.
Measurements and results: Of the
respondents 77% reported that they
had received adequate training on
providing oral care; most (93%)
also expressed the desire to learn
more about oral care. Oral care was
perceived to be high priority in me-
chanically ventilated patients (88%).
Cleaning the oral cavity was consid-
ered difficult by 68%, and unpleasant
as well as difficult by 32%. In 37%
of cases respondents felt that despite
their efforts oral health worsens over
time in intubated patients. Oral care
practices are carried out once daily
(20%), twice (31%) or three times
(37%). Oral care consists principally
of mouth washes (88%), mostly
performed with chlorhexidine (61%).
Foam swabs (22%) and moisture
agents (42%) are used less frequently
as well as manual toothbrushes (41%)
although the literature indicates that
these are more effective for thorough
cleaning of the oral cavity. Elec-
tric toothbrushes were never used.
Conclusions: In European ICUs oral
care is considered very important. It is
experienced as a task that is difficult to
perform, and that does not necessarily
succeed in ensuring oral health in
patients with prolonged intubation.
Oral care consists primarily of mouth
washes. The use of toothbrushes
should be given more attention.
Keywords Key words · Oral care ·
Mouth wash · Prevention · Intensive
care unit · Pneumonia
Introduction
Oral hygiene is a basic task for health care workers
(HCWs) caring for ICU patients [1, 2]. All patients may
suffer from poor oral health, but especially at risk are those
on mechanical ventilation (MV) because endotracheal
intubation facilitates bacterial adherence to the mucosa,
and because several drugs frequently used in ICUs may

cause xerostomia, which has a damaging impact on oral
health [3–5]. The primary objective of oral care is to
minimize dental plaque formation and accumulation of
oropharyngeal debris as these create an ideal environment
for pathogenic micro-organisms that may cause such
conditions as stomatitis and gingivitis [6, 7]. In this way
oral care can effectively maintain oral health. Addition-
ally, in patients on MV it may reduce the incidence of
pneumonia [8–12].
Notwithstanding the apparent advantages of adequate
oral care in ICU patients, this issue receives only modest
attention. The literature provides little information on the
current practice, training, and attitudes of HCWs regard-
ing oral care in ICU patients. The objective of this survey
was to determine the type and frequency of oral care in
European ICUs and the attitudes, beliefs, and knowledge
of HCWs regarding this issue.
Methods
A 27-item questionnaire was used that was developed by
a research team at the University of Louisville (Louisville,
Ky., USA) [13]. Due to the lack of a previously developed
and tested instrument, this team designed the questionnaire
based on a review of the literature and on the following re-
search questions: (a) What is the type and frequencyof oral
care provided to ICU patients? (b) What are the attitudes
and beliefs of ICU HCWs regarding oral care? (c) How are
ICU HCWs trained in oral care? This questionnaire, after
being pretested, was used to gather information related to
oral care practices, training, and attitudes among nurses in
ICUs across the United States in 2002 [13]. In addition
to the questionnaire, information regarding demographics
and nurses’ training experience was requested (Table 1).
The questionnaire was distributed to voting members
of the infection section of the European Society of Inten-
sive Care Medicine. Those willing to participate could then
contact other ICUs in their country of origin. Therefore
a response rate could not be calculated. Participation in the
survey was voluntary and anonymous. Fifty-nine question-
naires (one questionnaire per ICU) from seven countries
were available for analysis. Participating ICUs were from
Spain (n= 33), Greece (n= 12), France (n= 5), Belgium
(n= 3), Italy (n= 3), Germany (n= 1), Andorra (n=1),and
Turkey (n= 1). Table 1 presents the demographic charac-
teristics of respondents.
Measurements
Attitudes, beliefs, and knowledge
The assessment of respondents’ attitudes and beliefs used
a five-point Likert scale ranging from “strongly agree”
Table 1 Demographic characteristics of responders (n= 59)
Demographics n%
Shift pattern
Morning 24 40.7
Afternoon 3 5.1
Night 1 1.7
Rotating 30 50.8
Position
Registered nurse 54 91.5
Clinical assistant 3 5.1
Respiratory therapist 1 1.7
Other 1 1.7
Nurse’s education
3-year degree 47 79.7
Bachelor’s degree 1 1.7
Master’s degree 4 6.8
Other 2 3.4
Oral care training
Nursing school 9 15.3
Continuing education 8 13.6
In-service 25 42.4
Self-taught 1 1.7
More than one 15 25.4
Hospital type
University/academic 45 76.4
Private nonprofit 1 1.7
Private profit 2 3.4
Public 10 16.9
ICU type
Medical 6 10.2
Surgical 2 3.4
Trauma 3 5.1
Cardiac 1 1.7
Neurosurgical 1 1.7
Cardiosurgical 2 3.4
Polyvalent 44 74.6
(= 5) to “strongly disagree” ( = 1; Table 2). Respondents’
knowledge of current evidence that microaspiration
of oropharyngeal debris is a risk factor for ventilator-
associated pneumonia (VAP) was assessed by including
the following scenario in the questionnaire: “An 18-year-
old male was involved in an all terrain vehicle accident
five days ago and was admitted to your ICU. He has been
mechanically ventilated since admission and has now
developed pneumonia.” The respondent had to assess the
likelihood on a scale of 1–10 regarding each of the fol-
lowing being the mechanism of disease: (a) aspiration of
contaminated oropharyngeal secretions from oropharynx,
(b) transmission from HCWs hands, (c) transmission from
contaminated respiratory equipment, (d) preadmission
colonization, and (e) transmission from other patients
(Table 3).
Type and frequency of the provided oral care
Respondents were asked about the frequency of the use
the following supplies: foam swabs, manual toothbrushes,

Table 2 Attitudes regarding oral care
Strongly agree Somewhat agree Neither agree Somewhat disagree Strongly disagree
or disagree
n%n%n%n%n%
Oral care is a very high priority 52 88.1 6 10.2 1 1.7 0 0 0 0
Cleaning the oral cavity is 6 10.2 17 28.8 16 27.1 6 10.2 13 22.0
an unpleasant taska
The oral cavity is difficult to clean 15 25.4 25 42.4 7 11.9 6 10.2 6 10.2
The mouths of most ventilated patients 5 (8.5) 17 28.8 4 6.8 15 25.4 18 30.5
get worse no matter what I do
I have been given adequate training 26 44.1 19 32.1 8 13.6 4 6.8 2 3.4
in providing oral care
aOne respondent did not answer
Table 3 Response rates on the clinical scenario (see text) (IQR in-
terquartile range)
Assumed mechanism of disease Main response
Median IQR
Aspiration of contaminated secretions 8 6–9
Contamination from health care workers hands 4 3–6.25
Transmission from contaminated equipment 2 1–4.5
Preadmission colonization 3.5 1–7.25
Transmission from other patients 2 1–5
electric toothbrushes, moisture agents, toothpaste, and
mouthwash. If mouthwash was used, respondents were
asked to identify the type.
Oral care training
Two questions were about previous oral care training, and
three were about respondents’ attitudes towards additional
oral care information and training.
Hospital support and supplies
For the assessment of hospital’s policy regarding oral care
and the availability and adequacy of oral care supplies
the respondents were asked five questions to answered
on a Likert scale [ranging from “strongly agree” (= 5) to
“strongly disagree” (= 1)].
Results
Table 2 presents the results of the survey regarding atti-
tudes to oral care. On the item questioning knowledge
as to the mechanisms of disease in VAP, responses
demonstrated that respondents were generally aware that
microaspiration is the most probable mechanism of VAP
(Table 3). In 77% of cases the respondents expressed
the belief that they had received adequate training on
providing oral care in ICU patients (see Electronic Sup-
plementary Material, ESM, S.T1). Over 40% reported
receiving this training in-service and 15% in nursing
school. Interestingly, 68% denied having received oral
care training during nursing school.
The most common practice for providing oral care
was the use of mouthwashes (ESM, S.T2). These are
performed mostly with chlorhexidine and at least once
daily (ESM, S.T3). All respondents stated that they have
adequate time to provide oral care at least once daily
(ESM, T.S4). Most respondents believed nurses should be
responsible for cleaning the oral cavity of intubated pa-
tients, while a minority felt that a dentist-hygienist should
perform this task. Regarding the supplies for providing
oral care, 81% replied that they had adequate supplies.
However, 63% replied that they need better supplies and
equipments to perform oral care in ICU. Only one-third
found the toothbrushes provided by the hospital adequate;
it is interesting that 37% of the respondents replied that
toothbrushes were not available. Only 27% preferred
an electric toothbrush to a manual, and nearly the same
percentage suggested that the staff would be more likely
to brush patients’ teeth with an electric toothbrush than
with a manual one.
Discussion
To our knowledge this is the first survey on oral care prac-
tices in ICUs performed on a European scale. The results
show that oral care in ICU patients is regarded as a nursing
matter in most centers that participated in the survey. Over-
all, oral care is considered of high importance. However,
only a minority of respondents had received training or ed-
ucation on oral care in nursing school. The gap between
the lack of basic education and the skills needed in the ICU
is often compensated by in-service training. Still, most re-
spondents would like to receive more training in oral care.
This is consistent with the fact that a substantial propor-
tion of respondents consider oral care a difficult and un-
pleasant task that is potentially frustrating as most reported
that in spite of their efforts oral health in intubated patients

worsens over time. There seems to be an important chal-
lenge in the training nurses such that their attitude becomes
more positive. This may be achieved by providing ade-
quate equipment. For example, mouth washing is the most
frequently performed practice, but this is rather impracti-
cal in intubated patients. On the other hand, although elec-
tric toothbrushes have been shown to improve the quality
of oral care [14]; in no unit electric toothbrushes are used
(S.T5, S.T6, ESM). Indeed, lack of suitable equipment has
previously been pointed out as a fundamental impediment
to complying with guidelines among ICU staff [15, 16]. In
this regard it is likely that attitudes of HCWs would change
positively if innovativeand more practical methods for oral
care became available.
The results of our survey regarding attitudes of oral
care matches are in accord with those reported by Binkley
et al. [13] using the same questionnaire. Concerning
the type of oral care, however, there exist substantial
differences between the United States and Europe. In
European ICUs the use of foam swabs and moisturizers is
rather rare (ESM, S.T2), while in the United States these
are used very frequently (at least every 12 h in more than
90% of the respondents). The beneficial effect of foam
swabs, however, remains unconfirmed [17]. Also, manual
brushes and toothpaste are seldom used in European ICUs
whereas manual brushing with toothpaste is performed
once daily in about 40% of the practices in ICUs in the
United States [13]. The use of a toothbrush is a more
adequate tool for thorough mechanical cleaning of the
oral cavity [17]. Although not always easy to perform in
ICUs, this practice leads to improved oral health [18],
decreased gingival inflammation [19], and cost savings
by the elimination of toothettes [18]. While proven to be
superior to manual brushes, electric toothbrushes are very
rarely used in both European and United States ICUs [13,
14].
The emphasis in of oral care practice in Europe is
clearly on mouthwashes, principally with chlorhexidine.
Mouthwashing with chlorhexidine has been associated
with a decrease in dental plaque formation [20], a decrease
in the incidence of respiratory infections [8], VAP [9,
10, 20], and nosocomial infections in general [8]. Based
on a randomized, double-blind, placebo-controlled trial
Koeman et al. [12] reported a 65% reduced risk of VAP
associated with oral decontamination with chlorhexidine
applied every 6 h in intubated patients. Mori et al. [10]
also found a reduced risk of VAP when using a 20-fold
diluted povidone-iodine gargle combined with manual
toothbrushes every 8 h. This study, however, was not
randomized but rather used a historical cohort as control
group. The first step to take in improving oral care prac-
tices in Europe seems to be the promotion of manual or
better electric toothbrushes. The success of an educational
program depends on several aspects. Educational pro-
grams aimed at improving oral care should be supported
by an evidenced-based protocol and provided by qualified
instructors [21]. In-service training with direct clinical
contact has been shown to be more effective than passive
learning from textbooks [22]. To ensure a long-term
effect it is important to provide a multifaceted educational
program [23]. Furthermore, given the negative perception
of nurses towards oral care it is important to offer the
educational sessions in a positive way and to stress the
significance of the issue [24].
This study has limitations. First, there was the unequal
distribution of participating ICUs across Europe, and from
some countries no single unit responded. Secondly, the
questionnaire was developed to explore oral care practices
and attitudes in individual nurses, while in this survey it
was used to investigate practices among European ICUs.
Nevertheless, our results match those obtained in ICUs in
the United States [13]. It should also be noted that because
of the lack of a solid scientific basis the survey is likely to
reflect the personal opinion of the respondents rather than
practice supported by evidence-based guidelines. Another
potential bias in our survey is that over 75% of the partici-
pating ICUs were from university or academic institutions.
The survey carried out by Binkley et al. [13] in the United
States found that private hospitals provided more oral care
than university-affiliated centers. Furthermore, there exists
the problem of selection bias inherent in questionnaire
research. Although the survey was anonymous, it is to be
expected that units in which oral care is considered of high
importance were more likely to participate. As noted by
the team that developed the questionnaire, the instrument
lacks items regarding existing or planned protocols of
oral care [13]. The presence of protocols may influence
practice, either in frequency and/or quality. Additionally,
the questionnaire does not adequately distinguish between
oral care in intubated and that in nonintubated patients.
Neither does the questionnaire collect data regarding
the time spent on various types of oral care, which may
affect the attitude towards particular practices, such as
the use of toothbrushes. A study by Hanneman and
Cusick [25] found that daily rates of oral care in intubated
and nonintubated patients were 3.3 and 1.8, respectively.
In conclusion, in European ICUs oral care is consid-
ered of high importance and is generally carried out by
nurses. It is experienced as a task that is difficult to per-
form, and that does not necessarily succeed in ensuring
oral health in patients with prolonged intubation. Oral care
primarily consists of mouth washes, mostly with chlorhex-
idine. The use of toothbrushes should be given more atten-
tion as these are used only rarely while being more effec-
tive for thoroughly cleaning of the oral cavity.
Acknowledgements. The authors are indebted to all those who par-
ticipated in the survey and took the time to fill out the questionnaire.

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