The standard oral care routine in CCTC consists of BID and prn toothbrushing with toothpaste, BID application of chlorhexidine, intermittent cleansing with toothettes and the application of vaseline to the lips (see procedure for oral care).

For patients with thick oral secretions or coating of their teeth or tongue, enhanced removal may be facilitated by adding a regime of hydrogen peroxide. This should be performed in addition to the standard oral care procedure using the Sage (TM) oral care kit. The additional use of hydrogen peroxide should be discontinued once normal oral hygiene has been restored (while continuing with the standard oral care procedure).

Supplies Required:

  1. One Sage (TM) oral care kit (containing 2 toothettes plus lip moisturizer).
  2. Suction tubing connected to wall suction.
  3. PPE- non-sterile gloves, facemask and shield




Review Other Oral Care Procedures

  • Continue with standard oral care routine
  • Identify the time of the last chlorhexidine application (or other antibicrobial rinses including nystatin)
  • Wait at least 2 hours before hydrogen peroxide rinse
  • Discontinue use of hydrogen peroxide once normal oral hygiene has been restored.


Simultaneous use of chlorhexidine and hydrogen peroxide may reduce the effectiveness of the chlorhexidine.


Perform Oral Assessment:

  • Perform hand hygiene and don PPE.
  • To fully inspect oral cavity, use a flashlight and a 4 X 4 gauze to facilitate lifting/moving of the tongue
  • Inspect top, sides and undersurface of tongue. Assess lips, back of throat and mucous membranes for any bleeding, odor, discharge or evidence of skin breakdown or ulceration
  • Inspect teeth to observe for breakage, missing teeth, dental carries or recent trauma. Consider need for dentistry consult.
  • Remove any partial or full plates or dentures.
  • Palpate along cheeks, gum line and neck glands for signs of swelling, enlarged lymph nodes or abscess.
  • Review ETT or NG tube placement and assess for associated ulcers/early pressures; discuss with RRT if tube repositioning is needed
  • Document findings in AI record.



In accordance with the MoHLTC 4 moments of hand hygiene and LHSC infection control policiesin an effort to reduce risk of transmission of microorganisms and secretions.

Disruption of mucous membranes can be very painful and may increase risk for systemic infection.

Dental caries increase risk for abscesses/oral infections.



Activate Hydrogen Peroxide

  • Squeeze the pouch that contains the oral toothette
  • Do not open package until pouch is broken and toothette is saturated


Squeezing the pouch will release the hydrogen peroxide and moisten the toothettes


Clean mouth and teeth

  • Connect suction to toothette
  • Scrub along teeth, tongue, inside of cheeks and gum line using small circular motions without applying suction
  • When finished cleaning oral cavity, apply suction by placing thumb over suction vent
  • Discard toothette following use



Moisturize lips

  • Apply moisturizer to lips
  • Remove PPE and perform hand hygiene.



In accordance with the MoHLTC 4 moments of hand hygiene and LHSC infection control policies in an effort to reduce risk of transmission of microorganisms and secretions.




  • Document oral care in flow sheet
  • Document abnormal findings in AI record


Revised by: Brenda Morgan RN BScN MSc CNCC-C

Revised from: Dr. H Lapointe, Chief of Oral Surgery, UWO, Cathy Mawdsley, CNS Critical Care, LHSC:


Bergmans, D.C., Bonten, M., Gaillard, C.A., Paling, J.C., van der Geest, S., Tiel, F.H.,
Beysens, A.J., de Leeuw, P.W., Stobberingh, E.E. (2001). Prevention of ventilator-
associated pneumonia by oral decontamination. American Journal of Critical Care
Medicine. 164:382-388.

Fourrier, F., Can-Pottier, E., Boutigny, H., Roussel-Delvallez, M., Jourdain, M., Chopin,
C. (2000). Effects of dental plaque antiseptic decontamination on bacterial
colonization and nosocomial infections in critically ill patients. Intensive Care
Medicine. 26: 1239-1247.

Grap, M.J., Munro, C.L., Ashtiani, B., Bryant, S. (2003). Oral care interventions in
critical care: Frequency and documentation. American Journal of Critical Care.

Koeman, M., van der Ven, A.J., Hak, E., Joore, C. A., Kaasjager, K., de Smet, A.G.,
Ramsay, G., Dormans, T., Aarts, L.P., de Bel, E. E., Hustinx, W.N., van der Tweed, I.,
Hoepelman, A.M., Bonten, M.J. (2006). Oral decontamination with chlorhexidine
reduces the incidence of ventilator-associated pneumonia. American Journal of
Respiratory Critical Care Medicine. 173: 1348-1355.

Pneumatikos, I., Konstantonis, D., Tsagaris, I., Theodorou, V., Vretzakis, G., Danielides,
V., Bouros, D. (2006). Prevention of nosocomial maxillary sinusitis in the ICU: the
effects of topically applied andrenergic agonists and corticosteroids. Intensive Care
Medicine. 32: 532-537.

Schleder, B.J. (2004). You can make a difference in 5 minutes. Evidenced-Based
Nursing. 7:102-103.

Seguin, P., Tanguy, M., Laviolle, B., Tirel, O., Malledant, Y. (2006). Effect of
oropharyngeal decontamination by proviodine-iodine on ventilator-associated
pneumonia in patients with head trauma. Neourlogic Critical Care. 34:5 p.1514-

Last Update:March 23, 2010

LHSCHealth Professionals

Last Updated March 24, 2010 | © 2007, LHSC, London Ontario Canada