Intensive care is one of the most complex and delicate branches of medicine, dedicated to the treatment of critically ill patients with severe or potentially life-threatening conditions. These patients require constant monitoring and intensive treatments that include respiratory, hemodynamic, and pharmacological support. Severe clinical conditions and the prolonged use of medical devices, such as endotracheal tubes, profoundly alter the general and local physiological framework, including the oral cavity. This compromised environment favors the onset of various pathologies, particularly infectious ones, both locally (oral) and systemically (respiratory) (1).

Numerous studies highlight how patients admitted to intensive care units have a high incidence of oral cavity pathologies, often underestimated or inadequately treated due to the complexity of these individuals' general conditions. Among the most common issues is the alteration of salivary flow, which can lead to xerostomia, resulting in oral lesions and a greater predisposition to infections, such as those caused by Candida (2). Additionally, the decrease in immune defenses, due to pathological conditions and pharmacological treatments, makes patients more vulnerable to the development of caries and periodontal diseases. Furthermore, great attention should be paid to peri-implantitis, which can very easily lead to the formation of purulent inflammatory infiltrate (3).

Following a careful analysis of the most recent studies in the literature, it has emerged that critically ill patients have a high incidence of periodontal disease. Managing this aspect is crucial, as this condition can significantly affect overall health. Periodontitis could not only aggravate pre-existing conditions but also favor the development of new complications, such as lung infections, resulting from the migration of pathogens from the oral cavity to the respiratory tract (4).

Nosocomial pneumonias (HAP, Healthcare Associated Pneumoniae) account for about 25% of nosocomial infections in intensive care units (5). Nosocomial pneumonias are defined as lung infections that develop within 48 h of hospital admission and were not already incubating at the time of admission due to the composition of the oral microbiota, which undergoes a transformation towards more virulent organisms, increasing the risk of nosocomial infections (5).

Ventilator-associated pneumonia (VAP) develops primarily as a result of microaspiration of contaminated oropharyngeal secretions around the endotracheal tube cuff. Endotracheal intubation disrupts normal airway defenses, impairs cough reflexes, and facilitates the formation of biofilm on the surface of the tube, which serves as a reservoir for pathogenic microorganisms. Additional contributing factors include prolonged mechanical ventilation, supine positioning, sedation, and frequent airway manipulation (6).

Critically ill patients are particularly vulnerable to VAP due to the presence of multiple comorbidities such as chronic obstructive pulmonary disease, diabetes mellitus, cardiovascular disease, renal failure, malnutrition, and immunosuppression. These conditions, combined with altered immune responses and prolonged exposure to invasive devices and broad-spectrum antibiotics, significantly increase the risk of respiratory infections in the intensive care setting (6, 7).

Among the most common and feared nosocomial pneumonias (HAP, Hospital-Acquired Pneumonia) recorded in intensive care units, ventilator-associated pneumonia (VAP) is one of the most frequent and severe complications in intensive care units. VAP often develops due to bacterial colonization of the oral cavity and oropharynx, favored by poor oral hygiene and the use of ventilation devices that facilitate the migration of pathogens to the respiratory tract (5, 6).

Ventilator-associated respiratory infections represent a significant clinical challenge, with high rates of morbidity and mortality and are responsible for a considerable prolongation of hospital stays. This necessitates targeted preventive interventions, including optimal oral hygiene management. The decontamination of the oropharynx and the adoption of dental care protocols in intensive care are key elements to prevent the onset of respiratory complications. However, despite the growing attention to this issue, there remains ample room for improvement in the clinical practices adopted (5, 7, 8).

Numerous studies have demonstrated the effectiveness of preventive and therapeutic dental interventions in reducing respiratory infections, highlighting the need for greater integration of oral care within the management protocols of critically ill patients (5, 9, 10).

This article aims to systematically examine, through a scoping review, the possible dental management strategies for patients admitted to intensive care. The intent is to provide a comprehensive overview of current prevention and treatment practices, with particular attention to methodologies aimed at reducing the risk of respiratory infections, including VAP. The analysis of existing scientific literature will allow the identification of effective dental interventions, thereby contributing to improving the quality of care and clinical outcomes of patients admitted to intensive care units.

The literature search generated 88 references: of these, 44 duplicate articles and 2 guidelines were removed before screening. 42 articles were screened, from which 11 reviews and 3 articles without clear results were excluded. 28 articles were assessed for eligibility, of which 18 were excluded because they did not include oral cavity treatments and 2 because they did not include intensive care patients. In the end, 8 studies were included in the review (10–17).

The studied population included patients admitted to intensive care, with a portion of them undergoing mechanical ventilation. The average age of the patients ranged from 48 to 77 years, with a predominance of male patients (approximately 57%).

The evaluated oral hygiene interventions included plaque removal using toothbrushes, oral swabs, 0.12%–0.2% chlorhexidine, and povidone-iodine. Mechanical plaque removal was performed in 5 studies (10–13, 17), while the use of chlorhexidine was evaluated in 7 studies (10–15, 17). The use of povidone-iodine was less common, present in only one study (16). Interventions, outcomes, and complications from the selected articles have been reported in a table (Table 2).

The findings of our scoping review emphasize the critical importance of oral hygiene management in intensive care patients, particularly for preventing ventilator-associated pneumonia (VAP). VAP remains one of the most severe and frequent complications in intensive care units, contributing to high morbidity and mortality rates. Oral hygiene interventions, such as the use of chlorhexidine and mechanical plaque removal, have shown a significant impact in reducing VAP incidence. This aligns with previous research highlighting chlorhexidine's effectiveness in lowering oral bacterial load and preventing respiratory infections (5, 6).

Mechanical Plaque Removal: Combining mechanical plaque removal with chlorhexidine use yielded the most favorable outcomes in reducing VAP incidence and improving oral hygiene. While three studies (10–12) demonstrated a significant decrease in VAP incidence due to mechanical plaque removal, two studies did not find a significant reduction, indicating variability in results. This suggests the need for further research to optimize these protocols and better understand the conditions under which these interventions are most effective.

To address the temporal scope of the evidence base, we conducted an updated search to identify studies published after 2023. Recent syntheses provide additional context and highlight ongoing debate regarding the optimal antiseptic strategy. A 2024 network meta-analysis of randomized trials suggested that toothbrushing, particularly when combined with 0.12% chlorhexidine, ranked highly for VAP prevention, although the certainty of evidence was low (30). Conversely, another 2024 network meta-analysis reported no significant benefit of chlorhexidine at any concentration for preventing VAP and did not support its routine use (31). Moreover, implementation-oriented studies published in 2024–2025 emphasize that standardized, intensive oral care and interprofessional training may be key drivers of improved outcomes, irrespective of the specific antiseptic used (32–34).

Several studies have investigated the role of oral hygiene interventions in preventing ventilator-associated pneumonia in critically ill patients. Previous randomized controlled trials have demonstrated that mechanical plaque removal combined with chlorhexidine use significantly reduces oral bacterial load and the incidence of VAP compared with standard oral care alone. These findings are consistent with those reported by Bergmans et al. and de Lacerda Vidal et al., who showed a reduction in VAP incidence when structured oral hygiene protocols were implemented in mechanically ventilated patients.

More recent studies have emphasized the importance of professional dental involvement in intensive care units, highlighting improved oral health outcomes and a reduction in respiratory infections when dental care is integrated into multidisciplinary ICU teams. Our findings align with this evidence, supporting the concept that oral hygiene should be considered an essential component of VAP prevention bundles rather than an optional supportive measure.

The high prevalence of comorbidities among critically ill patients further supports the need for targeted preventive strategies. Poor oral health, periodontal disease, and increased oral bacterial load may act as modifiable risk factors for VAP, particularly in patients with compromised immune responses. Therefore, structured oral hygiene protocols should be considered an integral component of VAP prevention bundles in intensive care units.

It is essential to continue promoting research in this field to identify the best oral hygiene practices and develop evidence-based protocols. Future studies should focus on larger samples and long-term follow-up to evaluate the effectiveness and safety of oral hygiene interventions in intensive care patients. Additionally, exploring the use of new technologies and materials could further enhance oral hygiene and infection prevention.

This scoping review has several limitations that should be acknowledged. First, the number of available studies focusing specifically on oral hygiene interventions in mechanically ventilated intensive care patients remains limited. Second, the included studies show substantial heterogeneity in terms of study design, sample size, oral hygiene protocols, frequency of interventions, and outcome measures, which limits direct comparability. Additionally, follow-up periods were often short, potentially underestimating long-term outcomes and complications. Finally, some studies included small patient cohorts, which may have reduced statistical power. These limitations highlight the need for further large-scale, well-designed randomized controlled trials with standardized protocols.

Overall, the present scoping review provides an updated synthesis of the available evidence on oral hygiene management in critically ill patients, reinforcing the clinical relevance of structured oral care protocols and supporting their integration into routine intensive care practice.

The management of oral hygiene in critically ill patients admitted to intensive care is a fundamental aspect for preventing infectious complications, particularly ventilator-associated pneumonia (VAP). The literature review highlighted that the use of chlorhexidine, both as a mouthwash and gel, is effective in reducing the incidence of VAP due to its bactericidal and bacteriostatic properties. However, the effectiveness of chlorhexidine is maximized when combined with mechanical plaque removal, suggesting that an integrated approach is essential to achieve the best results.

The use of non-absorbable antibiotics has shown potential in reducing the oral microbial load but has not demonstrated a significant impact on patient mortality, thus limiting its use as a standard of care. Additionally, the adoption of oral hygiene protocols that include oropharyngeal decontamination and the use of appropriate tools, such as small-headed toothbrushes with soft bristles, is crucial for improving oral hygiene and reducing the risk of respiratory infections.

The collected evidence underscores the importance of a multidisciplinary approach that includes the involvement of specialized dentists within intensive care teams. Their expertise is essential for performing necessary procedures such as caries treatment, scaling, root planing, and drainage of oral abscesses. Interprofessional collaboration is crucial for ensuring optimal and holistic care, improving patient well-being, and reducing healthcare costs associated with prolonged hospital stays and infectious complications.

In conclusion, the integration of effective oral hygiene practices and the adoption of a multidisciplinary approach can significantly improve clinical outcomes for critically ill patients, reducing the morbidity and mortality associated with nosocomial infections. It is essential to continue promoting research and the implementation of evidence-based oral care protocols to optimize the management of patients in intensive care.