The incidence and clinical progression of oral lesions in a cohort of critically ill patients administered mechanical ventilation via orotracheal intubation were observed prospectively in the Intensive Care Unit (ICU) of the University of California, Davis Veterinary Medical Teaching Hospital. Oral cavities of these patients were examined within 24 hours of being placed on the ventilator and at least daily thereafter during ventilator therapy. As part of the study protocol, any lesion noted was treated. Twenty-one critically ill canine patients (median age of 7 yrs; range <1 to 19 yrs) were observed from 1 January 1995 through 31 August 1995. Over ninety percent (90.5%) of the observed patients developed oral lesions subsequent to being mechanically ventilated. Erosive and ulcerative mucosal lesions were the most frequently observed (15/43) with the tongue being the most frequently involved oral structure. Most of the observed soft tissue oral lesions appeared secondary to persistently applied pressure from teeth, mouth gags, endotracheal tubes, and other monitoring devices. Efforts taken to prevent persistently applied trauma, such as periodic positional changes of equipment and padding of susceptible structures, apeared effective in preventing oral lesions. There were indications of gastric reflux in 6 patients (28.6%), as evidenced by secretions in the oral cavity with a pH of <6 and containing digested blood. Ulcerative lesions in the subset of patients with gastric reflux seemed to worsen in severity with exposure to the low pH secretions. Over the course of the study, the ICU nursing staff developed an effective protocol for the care of the oral cavity: treating mucosal erosions and ulcers topically8 with a dilute chlorhexidine solution (0.05%), removing oral secretions via suction as needed, and padding persistently traumatized tissues with glycerin moistened gauze. Oral lesions in orotrachealy intubated and mechanically ventilated patients are predictable, preventable, and treatable. Most lesions are pressure induced, associated with monitoring/therapeutic equipment, and appear to be preventable with appropriate nursing protocls. Most observed oral lesions clinically improved with routine, periodic dilute chlorhexidine rinses and relief of applied pressure.