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Year : 2020  |  Volume : 31  |  Issue : 3  |  Page : 426-432
Knowledge, attitude and oral care practices for preventing ventilator-associated pneumonia among critical care nurses – A questionnaire study

1 Private Practitioner, Manipal College of Dental Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
2 Department of Periodontology, Manipal College of Dental Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
3 Department of Periodontology and Endodontics, School of Dental Medicine, University of Buffalo, New York, NY, USA

Click here for correspondence address and email

Date of Submission30-Aug-2016
Date of Decision27-Dec-2018
Date of Acceptance16-Apr-2019
Date of Web Publication06-Aug-2020


Background: A cross-sectional study was conducted among intensive care unit (ICU) nurses in private hospitals in India to identify knowledge and practice of ICU nurses in the prevention of ventilator-associated pneumonia (VAP). Methods: Knowledge of 135 nurses working in ICU was tested using a questionnaire consisting of 18 questions. Fourteen forms were excluded from the statistical analysis due to incomplete data entry by the participants. The data of 121 filled questionnaires were analyzed. The information letters, consent forms, and questionnaires were handed to ICU nurses by Research assistant. Data were coded and entered into SPSS version for descriptive and inferential statistics. Results: A majority of the participants perceived oral care as a necessity in all critically ill patients. Nurses were generally aware of the most likely mechanism of acquiring pneumonia. The type and frequency of oral care varied widely. Many of them stated that they had adequate supplies to provide oral care. Although a majority of nurses had some formal training in oral care, they would appreciate an opportunity to enhance and improve their knowledge and skills. Conclusion: The methods of oral care provided vary widely. In summary, randomized controlled trial to date has demonstrated that tooth brushing is associated with a trend toward lower rates of VAP in intubated mechanically ventilated critically ill patients. But it is also to be noted that there was no clear difference between electric and manual tooth brushing. In-house training and workshop can provide required skills needed for the betterment of the treatment provided.

Keywords: Intensive care unit nurses, oral care, ventilator-associated pneumonia

How to cite this article:
Mannava Y, Nayak SU, Uppoor A, Naik D, Maddi A. Knowledge, attitude and oral care practices for preventing ventilator-associated pneumonia among critical care nurses – A questionnaire study. Indian J Dent Res 2020;31:426-32

How to cite this URL:
Mannava Y, Nayak SU, Uppoor A, Naik D, Maddi A. Knowledge, attitude and oral care practices for preventing ventilator-associated pneumonia among critical care nurses – A questionnaire study. Indian J Dent Res [serial online] 2020 [cited 2022 Oct 7];31:426-32. Available from:

   Introduction Top

Ventilator-associated pneumonia (VAP) is defined as a type of pneumonia in a patient receiving mechanical ventilation that was not present at the time of admission to hospital or that occurs 48 h after intubation and mechanical ventilation. VAP increases the risk of mortality, hospital stay, and cost factor. The risk of bacterial pulmonary infection increases by intubation and mechanical ventilation due to invasive endotracheal tube.[1] Since the tube is located in the trachea, this permits direct entry of bacteria into the lower respiratory tract. The absence of the cough reflex and excessive mucus secretion in the mechanically ventilated patients further facilitates the bacterial colonization in the respiratory tract.

The change in the oral flora, primarily gram-negative organisms, has been seen in patients in the intensive care unit (ICU) within a time period of 48 h. Dental plaque can provide an environment for microorganisms that cause VAP, and dental plaque of patients in the ICU can be colonized by potential respiratory pathogens such as methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa.[2],[3]

Early diagnosis and timely management of possible complications may contribute to decrease the incidence of VAP.[4] As the patients admitted in the ICU totally are dependent on the caregivers, the knowledge, attitude, and practices followed by these nurses influence the status of patients to a major extent. The lower number of cases and lack of adequate nursing staff (which should ideally be 1:1) may adversely affect the quality of care given to the patients and may be one of the reasons for increased incidence of VAP.[5] There are 21 strategies for prevention of VAP and these are divided into 10 physical strategies, three positional strategies, and eight pharmacological strategies.[6],[7]

ICU nurses are in the best position to put the above strategies into practice as they are at the patient's bedside 24 h a day, and therefore they play an important role in the prevention of VAP. Unfortunately, oral health problems are usually surpassed by other serious needs in ICU-admitted patients. Oral care can be compromised by critical illness and by mechanical ventilation and is influenced by nursing care.[8],[9],[10] Nurses must have an awareness of the problem and the knowledge on the above prevention strategies so as to adhere to such practices. Trained and knowledgeable nurses are very important and required to make right decisions in patient care and minimize risks to patients. Various measures to prevent VAP have been reported in the literature;[11] however, there are very few data concerning nurses' knowledge and oral care practices on VAP prevention. Even though VAP is a serious problem in developed countries, the lowest incidences in developing countries may be contributed by inadequate knowledge and awareness about the problem which may go unaddressed, many times.

Although evidence-based oral care protocols and oral preventive measures for VAP have been published, there is little information on current practice, oral care training, and nurse's attitude. Therefore, this questionnaire-based study is an attempt to understand the attitudes, knowledge, and guidelines of oral care followed by critical care nurses.

   Materials and Methods Top

The present cross-sectional study involved collection of data regarding knowledge, attitude, and practices of nurses providing services in ICUs in a private hospital. The Institutional Ethical Committee approval was obtained and each participant was accessed single time in the study period. Based on the research questions and review of literature, a questionnaire was designed by the research team to gather information from the ICU nurses after obtaining an informed consent from every participant. The study questionnaire was validated by a subject expert. Participation in the survey was anonymous and voluntary. Questionnaire consisting 18 questions was distributed among the ICU nurses and nursing students who were willing to participate in the study.

Data were collected from June to December 2015. A close-ended questionnaire with information letter and a consent form attached to it was handed out by the principal investigator of the research to ICU nurses. A code number was assigned to the participants instead of name or name column. Participants were told to sign the consent form. The questionnaires were in English because all nurses and students in this hospital were trained using English language. Consent forms and filled questionnaires were placed into sealed envelopes by the research member and taken from each unit daily.

Demographic details including name (code), age, sex, and designation of each participant were added in the questionnaire. Among knowledge-based questions, participants were asked about the importance and type of microorganisms and frequency of pneumonia in ICUs. The assessment of the questions was done on a direct yes or no options or multiple choice answers. Questions regarding type of oral care provided were included with the options oral rinse, brushing, both, and none to choose. Also, frequency of oral care with options once a day, twice daily, once in two days, even less, and never was included. Comparative questions regarding “toothbrushes better than swabs” and “can tooth brushing be replaced by mouth rinses” were added with option yes or no to choose. Documentation and use of checklists for oral care in the ICU were added to the questionnaire with yes or no options to assess the importance and oral care provided. Two questions on the availability of supplies provided by the hospital and any additional measures taken in ICU patients were added.

Attitude-based questions were based on the questionnaire developed by Binkley et al. (2004).[11] A 5-point Likert scale ranging from “strongly agree” (= 5) to “strongly disagree” (= 1) was used for the assessment of respondent's attitude. Nurses training and their attitude toward learning better methods to provide effective oral care were added to the questionnaire.

   Results Top

A total of 135 questionnaires were distributed among the nurses and nursing students. Fourteen questionnaires were excluded from analysis due to incomplete or multiple answers. Thus, data from 121 forms were subjected to statistical analysis. SPSS version 20 was used for the analysis.

Chi-square test was applied among the two groups and descriptive statistics was also used. In 121 study participants, 47 were nurses with mean age of 47.34 ± 5.45 years, and 75 were nursing students and their mean age was 27.92 ± 5.32 years.

As shown in [Graph 1], among the nursing group, 70.2% and 42.7% in nursing student group disagreed with chlorhexidine mouth wash can replace toothbrush. There was a statistical significant difference with P value of 0.003. In the study population of 88.0% (N = 66) nursing students, 72.3% (N = 34) of nurses said they take additional oral care in patients with VAP in the ICU. There was a statistical significant difference with P value of 0.027 [Graph 2]. There was a statistical significant difference in the attitude regarding oral care practice among ICU-admitted patients. As shown in [Graph 3], a majority of the nursing students disagreed that cleaning oral cavity is an unpleasant task. But both the groups agreed that cleaning of oral cavity is not an easy task [Graph 4]. Both the groups gave a statistically significant answer for the question regarding whether they feel the mouths of most ventilated patients get worse no matter what you do. Ventilated patients get worse irrespective of oral care practice. The P value was 0.13.

About 97.9% of nurses and 100% nursing students agreed that microorganisms in the mouth can cause infections.

When a question was asked regarding the different microorganisms, there was a mixed response. About 40.4% of nurses and 53.3% of nursing students felt Staphylococcus aureus is the major organism. Pseudomonas aeruginosa was felt as the commonly isolated organism by 40.4% of nurses and 10.7% of nursing students. Least response was given for Acinetobacter species. Around 17% of nurses and 36% of nursing students felt all the above-mentioned organisms are responsible for ICU infection. There was no statistically significant difference among the group. Approximately 76.6% of nurses and 62.7% of nursing students felt they have adequate training for ICU-admitted patient's oral care, whereas 23.4% of nurses and 37.3% of nursing students felt they need to update their training in oral care maintenance. About 17% nurses and 32% of nursing students prefer oral rinse as oral care aid for ICU patients, whereas toothbrush was preferred by 12.8% of nurses and 4% of nursing students. A combination of both (oral rinse + tooth brush) was opted by 27.7% of nurses and 29.3% of nursing students. About 42.6% of nurses and 34.7% of nursing students said they do not prefer oral rinse or tooth brush. Chi-square test showed no statistical significance with P value of 0.196. A majority of nurses and nursing students said toothbrushes are better than foam swabs in plaque control. There was a mixed response by the both the groups regarding frequency of oral hygiene in ventilator patients. They said oral hygiene practice ranged from once daily, twice daily to once in two days, or as/when needed. About 85.1% of nurses and 83.1% of nursing students said they document the oral care immediately once it is done. Around 46.8% of nurses and 33.3% of nursing students said they follow oral hygiene checklist, but 53.2% of nurses and 66.7% of nursing students felt there is no proper checklist pertaining to oral care measures that has been implemented in ICU-admitted patients. Chi-square test showed P value of 0.098. Of 121 participants, 107 of participants (nurses 89.4% and 86.7%) were happy with the oral care materials provided by the hospitals. A total of 66% of nurses and 69.3% of nursing students agreed that maintenance of oral care in patients in ICU has high priority to avoid infection/complications. Although 83% of nurses and 85.3% of nursing students believe that they have adequate training in oral hygiene practice in ICU-admitted patients, 81% of participants want to update their knowledge regarding this aspect to help their patients.

   Discussion Top

This study included nurses and nursing students as study participants. The results of this survey demonstrated that nurses and nursing students were generally aware that microorganisms can cause infection and also pneumonia is often developed in ICU. Both the groups felt Staphylococcus species and Pseudomonas aeruginosa are the common isolated organisms which is in accordance with the study by Minori et al.[5] Earlier studies have found Streptococcus pneumoniae, Haemophilus influenzae, Pseudomonas aeruginosa, and Staphylococcus species in samples from the human oral cavity and in nasopharyngeal secretions. All these bacteria have the potential to cause infectious respiratory diseases such as pneumonia resulting from salivary bacterial aspiration during mechanical ventilation. Poor oral hygiene can breed these microorganisms in patients' oral cavities putting the patient at high risk of infections.[5],[12]

The primary objective of oral care is to minimize dental plaque formation and accumulation of oropharyngeal debris, aspiration of which is known to cause transmission of bacteria into lungs, resulting in pneumonia. In this study, a combination of tooth brushes and mouth rinses was commonly used to reduce dental plaque, and it is suggested to use them minimum once in a day. This differs from the oral care provided by developed countries.[12],[13] In the United States, swabs and moisturizers are frequently used at least every 12 h, and according to European studies around 40% were reported to use toothbrush but the emphasis is on use of mouthwashes with chlorhexidine.[13] A majority of study participants opined that mouth washes cannot replace mechanical cleansing and the efficacy of swabs and foams remains unconfirmed. This is in accordance with an earlier study by Ames et al.[14] Although this study participants felt oral care is not easy to perform and time-consuming in patients in ICU, toothbrushes adequately reduces dental plaque, gingival inflammation, and are also cost-effective.[15],[16] Proper training and different methods to ease their use can make toothbrushes an adequate tool in providing oral hygiene in patients in ICU.

Even though a majority of study participants had a basic training on oral care protocol they still wish to update their knowledge. which was in agreement with the earlier studies.[17],[18] Many nurses opined that cleaning of oral cavity is difficult and a little unpleasant task. This is in agreement with a study by Alotaibi et al.,[19] whereas nursing students felt it not a unpleasant task. These difficulties and attitude can be compensated by in-service training of all the nurses and conducting regular workshops on oral care to keep them informed about the recent advances in this field.[17] A majority of the participants were keen in acquiring more knowledge and learning new methods in providing oral hygiene. As mentioned in the study by Aljaafreh et al.,[20] even this study participants felt written standards, guidelines, or protocol available in nurses' hands throughout the day in their work area could improve the care of such patients. Despite all the efforts, participants also mentioned the continuous decline in oral hygiene. The use of an assessment tool and also providing a bedside oral care kit will remind the healthcare workers about the issue of oral care in patients in ICU. Strict protocols with documentation and checklist of oral care also help in effective monitoring of the oral hygiene, thus reducing the risks of oral contamination.


Due to the lack of structured questionnaire available to scale oral hygiene practices in ICUs, the present questionnaire was designed by the research team to investigate the practices and attitude of ICU. The potential bias in our study is the majority of the participants were from academic institutions and single private hospital units. From previous studies, it was shown that private hospitals provide better oral care. The present questionnaire did not add details of training undertaken by nurses and years of experience. Also in the oral care practices, questions regarding the time spent on different types of oral care were not included.

   Conclusion Top

In conclusion, this survey is an initial attempt to understand the oral care provided in ICUs in India. Oral care is considered as high priority and is performed regularly, but the lack of proper training and protocols limits the effectiveness of the care taken. The present practices were shown to vary widely among the nurses including swabs, toothbrushes, mouth rinses, or both. The use of toothbrushes should be given more attention along with mouth rinses as adjuvant. Further studies including both private and public health sectors should be conducted to understand the present scenario on oral care which helps in designing proper protocols according to the needs of the place and patients.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   Questionnaire Top

Knowledge, attitude, and oral care practices for preventing ventilator-associated pneumonia among critical care nurses and nursing students – a questionnaire study

Name: (code):


Gender: Male/Female

Designation: Nurse/nursing student

  1. Do you think that microorganisms in the mouth can cause infections?

  2. Yes □No □

  3. Which is the most commonly isolated organism in your ICU?

  4. A. Staphylococcus aureus □ B. Pseudomonas aeruginosa

    C. Acinetobacter species □ D. Enteric species □-E. All the above □

  5. How often pneumonia is developed in ICU patients?

  6. A. Very often □ B. Often □

    C. Rare □ D. Very rare □ E. Not at all related □

  7. Are you trained specially in oral care?

  8. Yes □ No □

  9. What type of oral hygiene practices do you use before using ventilators in patients?

  10. A. Oral rinse □ B. Brushing □

    C. Both □ D. None □

  11. Are toothbrushes better than foam swabs for plaque removal?

  12. Yes □ No □

  13. Can chlorhexidine gluconate mouth rinse take the place of tooth brushing?

  14. Yes □ No □

  15. How often oral hygiene will be performed in ventilator patients?

  16. A. Once a day □ B. Twice a day □

    C. Once in two days □ D. Even less □ E. Ever □

  17. Do you document the oral care immediately after the care is done?

  18. Yes □ No □

  19. Do you use checklist for oral care?

  20. Yes □ No □

  21. Do hospitals provide adequate supplies for oral care?

  22. Yes □ No □

  23. Do you take any additional oral care do you take in patients with ventilator-associated pneumonia in ICU?

  24. Yes □ No □


  25. Is oral care of high priority in intensive care patients?

  26. Strongly agree □ Somewhat agree □

    Neither agree or disagree □ Strongly disagree

  27. Cleaning the oral cavity is an unpleasant task?

  28. Strongly agree □ Somewhat agree □

    Neither agree or disagree □ Strongly disagree □

  29. The oral cavity is difficult to clean?

  30. Strongly agree □ Somewhat agree □

    Neither agree or disagree □ Strongly disagree □

  31. The mouths of most ventilated patients get worse no matter what you do?

  32. Strongly agree □ Somewhat agree □

    Neither agree or disagree □ Strongly disagree □

  33. I have been given adequate training in providing oral care?

  34. Strongly agree □ Somewhat agree □

    Neither agree or disagree □ Strongly disagree □

  35. Would you like to learn more about the best way to provide oral care?

Strongly agree □ Somewhat agree □

Neither agree or disagree □ Strongly disagree

   References Top

Amaral SM, Cortês Ade Q, Pires FR. Nosocomial pneumonia: Importance of the oral environment. J Bras Pneumol 2009;35:1116-24.  Back to cited text no. 1
El-Solh AA, Pietrantoni C, Bhat A, Okada M, Zambon J, Aquilina A, et al. Colonization of dental plaques: A reservoir of respiratory pathogens for hospital-acquired pneumonia in institutionalized elders. Chest 2004;126:1575-2.  Back to cited text no. 2
Heo SM, Haase EM, Lesse AJ, Gill SR, Scannapieco FA. Genetic relationships between respiratory pathogens isolated from dental plaque and bronchoalveolar lavage fluid from patients in the intensive care unit undergoing mechanical ventilation. Clin Infect Dis 2008;47:1562-70.  Back to cited text no. 3
Rello J, Ollendorf DA, Oster G, Vera-Llonch M, Bellm L, Redman R, et al. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest 2002;122:2115-21.  Back to cited text no. 4
Okuda M, Kaneko Y, Ichinohe T, Ishihara K, Okuda K. Reduction of potential respiratory pathogens by oral hygienic treatment in patients undergoing endotracheal anesthesia. J Anesth 2003;17:84-1.  Back to cited text no. 5
Muscedere J, Dodek P, Keenan S, Fowler R, Cook D, Heyland D; VAP Guidelines Committee and the Canadian Critical Care Trials Group. Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: Diagnosis and treatment. J Crit Care 2008;23:138-47.  Back to cited text no. 6
Muscedere JG, Martin CM, Heyland DK. The impact of ventilator-associated pneumonia on the Canadian health care system. J Crit Care 2008;23:5-10.  Back to cited text no. 7
Osman MA, Aggour RL. Oral care practices in Egypt intensive care units – A national survey. J Periodontal Med Clin Pract 2014;01:172-82.  Back to cited text no. 8
Labeau S, Vandijck DM, Claes B, Van Aken P, Blot SI. Questionnaire preventing ventilator-associated pneumonia: An evaluation critical care nurses' knowledge of evidence-based guidelines for preventing ventilator-associated pneumonia: An evaluation questionnaire. Am J Crit Care 2007;16:371-7.  Back to cited text no. 9
Lloyd TE, Frost PJ, Rees JS. A pilot audit of oral health in mechanically ventilated critically ill patients. J Disabil Oral Health 2011;12:114-20.  Back to cited text no. 10
Binkley C, Furr A, Carrico R, McCurren C. Survey of oral care practices in US intensive care units. Am J Infect Control 2004;32:161-9.  Back to cited text no. 11
Vieira Colombo AP, Magalhães CB, Hartenbach FA, Martins do Souto R, Macielda Silva-Boghossian C. Periodontal-disease-associated biofilm: A reservoir for pathogens of medical importance. Microb Pathog 2016;94:27-34.  Back to cited text no. 12
Rello J, Koulenti D, Blot S, Sierra R, Diaz E, DeWaele JJ, et al. Oral care practices in intensive care units: A survey of 59 European ICUs. Intensive Care Med 2007;33:1066-70.  Back to cited text no. 13
Ames NJ. Evidence to support tooth brushing in critically ill patients. Am J Crit Care 2011;20:242-50.  Back to cited text no. 14
Needleman IG, Hirsch NP, Leemans M, Moles DR, Wilson M, Ready DR, et al. Randomized controlled trial of toothbrushing to reduce ventilator-associated pneumonia pathogens and dental plaque in a critical care unit. J Clin Periodontol 2011;38:246-52.  Back to cited text no. 15
Pearson LS, Hutton JL. A controlled trial to compare the ability of foam swabs and toothbrushes to remove dental plaque. J Adv Nurs 2002;39:480-9.  Back to cited text no. 16
Turner C, Lawler J. Mouth care practices in nursing and research-based education: An historical analysis of instructional nursing texts 1870-1997. Int Hist Nurs J 1999;4:29-35.  Back to cited text no. 17
Miranda AF, de Paula RM, de Castro Piau CG, Costa PP, Bezerra AC. Oral care practices for patients in Intensive Care Units: A pilot survey. Indian J Crit Care Med 2016;20:267-73.  Back to cited text no. 18
[PUBMED]  [Full text]  
Alotaibi AK, Alotaibi SK, Alshayiqi M, Ramalingam S. Knowledge and attitudes of Saudi intensive care unit nurses regarding oral care delivery to mechanically ventilated patients with the effect of healthcare quality accreditation. Saudi J Anaesth 2016;10:208-12.  Back to cited text no. 19
Alja'afreh MA, Mosleh SM, Habashneh SS. Nurses' perception and attitudes towards oral care practices for mechanically ventilated patients. Saudi Med J 2018;39:379-85.  Back to cited text no. 20

Correspondence Address:
Dr. Ashita Uppoor
Department of Periodontology, Manipal College of Dental Sciences, Manipal Academy of Higher Education, Manipal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijdr.IJDR_611_16

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