Table 1.

Research priorities in the field of oral hygiene for ICU patients

Topic	Focus and outcome	Suggested approach and points of interest
Oral assessment	Oral assessment tool for ICU patients Outcome: separate tools for intubated and non-intubated patients, respectively	Development—reliability and validity testing. Multidisciplinary cooperation with dental professionals
Type of toothbrush	Manual versus powered Bristle size, shape and type Outcome: plaque reduction	Randomized controlled trial (RCT). Blinding not possible—cave performance bias, same oral care regimens in comparable groups. Independent blinded assessment of outcomes and assessment of compliance highly recommended. Consider use of split-mouth design
Mouthwashes	Chlorhexidine gluconate Outcome: safety	Preclinical trials on toxicity and pharmacokinetics. No RCTs given the current state of the science
	Alternatives to CHG including povidone iodine, saline, bicarbonate, triclosan and furacilin Outcome: effectiveness in chemically cleaning the oral cavity	Separate randomized controlled trials or multiple-armed RCTs or factorial design. Cave, the latter rely on the assumption of no interaction between treatment arms. Avoid split mouth design due to the high possibility of carry-across effects
Solutions for moistening the oral cavity	Saliva substitutes and oral moisturizers Outcome: effectiveness in hydrating the oral cavity and lips	Same as above
Frequency	Optimal frequency for various aspects of daily oral hygiene (teeth brushing, moisturizing, mouthwash) Outcome: oral health as measured through specific, valid and reliable oral assessment tools for intubated and non-intubated ICU patients, respectively	Valid and reliable oral assessment tool needs to be developed first. Then, separate randomized controlled trials or multiple armed RCTs or factorial design. Cave, the latter rely on the assumption of no interaction between treatment arms
Best practices for ICU patients with specific oral needs	Best oral hygiene practices for patients with, e.g. dental prostheses, following maxillofacial surgery, oral health problems, …	Multidisciplinary cooperation with dental professionals