A prospective study was done to compare four different methods of securing oral endotracheal tubes: adhesive tape (A), Twill tape (T), Twill tape with FlexBlue bite block (TFXB), and Velcro tie with FlexBlue (VFXB), used on sequential days. Thirty-six patients were enrolled for 136 patient-days and 18 had complete 4-day cycles. The methods were evaluated twice daily by nurses, respiratory therapist, and patient, on a five-point Likert scale with regard to oral hygiene, patient comfort, nurse satisfaction, and ease of use. Tube movement relative to the incisor teeth was measured at end of shift, the use of a bite block was noted, and near extubations were documented. Analysis of variance and Student's t test with Bonferroni correction were performed. Adhesive tape had 33 patient-days, 0.4 +/- 0.7 cm movement, 3.4 +/- 0.9 oral hygiene, 4.0 +/- 0.8 comfort, 4.2 +/- 0.6 nurse satisfaction, and 4.2 +/- 0.7 ease of use. Twill tape had 34 patient-days, 0.7 +/- 1.1 cm movement, 3.0 +/- 0.7 oral hygiene, 3.1 +/- 0.9 comfort, 2.8 +/- 1.0 nurse satisfaction, and 3.3 +/- 1.1 ease of use. Twill tape with FlexBlue bite block had 35 patient-days, 1.3 +/- 2.0 cm movement, 2.5 +/- 1.2 oral hygiene, 1.9 +/- 1.1 comfort, 1.9 +/- 1.0 nurse satisfaction, and 2.1 +/- 1.1 ease of use. Velcro tie with FlexBlue had 34 patient-days, 0.8 +/- 1.0 cm movement, 1.9 +/- 1.2 oral hygiene, 1.5 +/- 1.4 comfort, 1.6 +/- 1.0 nurse satisfaction, and 1.8 +/- 1.1 ease of use. Statistical analysis showed no difference between the groups for tube movement. Method A was statistically superior to VFXB and TFXB on all other parameters, and T on all except oral hygiene. Twill tape was superior to VFXB on all, and TFXB on patient comfort, nurse satisfaction, and ease of use. There was no significant difference between TFXB and VFXB on any measured parameter. Adhesive tape and T required an oral airway on only 14 days compared with 69 days of FlexBlue use. Extubation on 2 and near extubation occurred on 18 occasions with FlexBlue use and only once with T and accounted for most decisions to change securing method. We cannot recommend the use of the FlexBlue system for securing oral endotracheal tubes.