A systematic review of the preventive effect of oral hygiene on pneumonia and respiratory tract infection in elderly people in hospitals and nursing homes: effect estimates and methodological quality of randomized controlled trials

Association between pneumonia and oral care in nursing home residents

Pneumonia remains the leading cause of death in nursing home residents. The accumulation of dental plaque and colonization of oral surfaces and dentures with respiratory pathogens serves as a reservoir for recurrent lower respiratory tract infections. Control of gingivitis and dental plaques has been effective in reducing the rate of pneumonia but the provision of dental care for institutionalized elderly is inadequate, with treatment often sought only when patients experience pain or denture problems. Direct mechanical cleaning is thwarted by the lack of adequate training of nursing staff and residents' uncooperativeness. Chlorhexidine-based interventions are advocated as alternative methods for managing the oral health of frail older people; however, efficacy is yet to be demonstrated in randomized controlled trials. Development and maintenance of an oral hygiene program is a critical step in the prevention of pneumonia. While resources may be limited in long-term-care facilities, incorporating oral care in daily routine practice helps to reduce systemic diseases and to promote overall quality of life in nursing home residents.

The impact of hospitalization on oral health: a systematic review

BACKGROUND

Poor oral health of hospitalized patients is associated with an increased risk of hospital-acquired infections and reduced life quality.

OBJECTIVES

To systematically review the evidence on oral health changes during hospitalization.

DATA SOURCES

Cochrane library, Medline, OldMedline, Embase and CINAHL without language restrictions.

STUDY ELIGIBILITY CRITERIA

Observational longitudinal studies.

DATA APPRAISAL AND SYNTHESIS METHODS

Two independent reviewers screened studies for inclusion, assessed the risk of bias and extracted data. Risk of bias was assessed using the Newcastle-Ottawa assessment scale. A narrative synthesis was conducted.

RESULTS

Five before and after studies were included. The data suggest a deterioration in oral health following hospitalization with an increase in dental plaque accumulation and gingival inflammation and a deterioration in mucosal health.

LIMITATIONS

While before and after studies are at a general risk of bias, other specific study characteristics were judged to have a low risk of bias. However, methodological issues such as unvalidated outcome measures and the lack of assessor training limit the strength of the evidence.

CONCLUSION

Hospitalization is associated with a deterioration in oral health, particularly in intubated patients.

Hospitalisation associated with a deterioration in oral health

DATA SOURCES

Ovid MEDLINE and Ovid OLDMEDLINE (January 1950 to January 2010), CINAHL (1982 to January 2010), Cochrane Library (up to 2010) and EMBASE (1981 to January 2010), bibliographies of potentially relevant reports and reviews, handsearching of Community Dentistry and Oral Epidemiology, Gerodontology, Journal of Disability and Oral Health and Special Care in Dentistry.

STUDY SELECTION

Longitudinal prospective observational studies in individuals of all ages being hospitalised, that assessed changes of the following outcomes: tooth loss, any measures of periodontal health, dental caries and stomatological diseases. There were no language restrictions.

DATA EXTRACTION AND SYNTHESIS

One reviewer scanned the titles and abstracts to select studies. Potentially eligible studies were screened by two reviewers who also data extracted using specially designed forms. Quality was assessed by both reviewers using the Newcastle-Ottawa scale for cohort studies. The authors assessed whether a power calculation was reported for each study and, if so, the magnitude of a change that the study was powered to detect. Heterogeneity between studies was anticipated so a narrative review was planned.

RESULTS

Five studies were included and all were assessed to be adequately representative and had sufficient follow-up. Outcome assessments were adequate but validity of the outcome measures was found to be subjective. One investigation included children only, whilst the remainder included adults only. Four of the studies were in intensive care units. Duration of hospitalisation was 5-20 days. This was insufficient a period for caries to develop. A power calculation was reported in only one study. Three out of four studies that reported on plaque accumulation found increasing levels of plaque accumulation during hospitalisation, whilst one did not. Two of three studies assessing gingival inflammation found a statistically significant increase. Two studies found a statistically significant increased incidence of mucositis in intubated patients but not in non-intubated patients.

CONCLUSIONS

Hospitalisation is associated with a deterioration in oral health, particularly in intubated patients.

The association between oral microorgansims and aspiration pneumonia in the institutionalized elderly: review and recommendations

Aspiration pneumonia is a leading cause of illness and death in persons who reside in long-term-care facilities and, combined with the lack of proper oral health care and services, the risk of aspiration pneumonia rises. The purpose of this article is to review recent literature on oral hygiene and oral care in long-term-care facilities and report new findings regarding associated risks for aspiration pneumonia, as well as research on oral care and health outcomes. The PubMed MeSH database was utilized to direct a specific search by entering terms "aspiration pneumonia" and "oral hygiene" from 1970 to 2009, which yielded 34 articles. The Ovid and Google Scholar databases were utilized as well and provided no additional references for the two terms. A manual search of references from other articles, including three systematic reviews published over the past decade, provided additional information regarding oral microorganisms and respiratory pathogens, as well as investigations of oral care. Finally, a brief but comprehensive introductory review was organized regarding oral microorganisms, biofilm, periodontal disease, and pneumonia to establish a framework for discussion. Overall, studies suggest (1) an association between poor oral hygiene and respiratory pathogens, (2) a decrease in the incidence of respiratory complications when patients are provided chemical or mechanical interventions for improved oral care, (3) the complex nature of periodontal disease and aspiration pneumonia make direct connections between the two challenging, and (4) additional studies are warranted to determine adequate oral hygiene protocols for nursing home patients to further reduce the incidence of aspiration pneumonia.

Oral microbiota and cancer

Inflammation caused by infections may be the most important preventable cause of cancer in general. However, in the oral cavity the role of microbiota in carcinogenesis is not known. Microbial populations on mouth mucosa differ between healthy and malignant sites and certain oral bacterial species have been linked with malignancies but the evidence is still weak in this respect. Nevertheless, oral microorganisms inevitably up-regulate cytokines and other inflammatory mediators that affect the complex metabolic pathways and may thus be involved in carcinogenesis. Poor oral health associates statistically with prevalence of many types of cancer, such as pancreatic and gastrointestinal cancer. Furthermore, several oral micro-organisms are capable of converting alcohol to carcinogenic acetaldehyde which also may partly explain the known association between heavy drinking, smoking, poor oral health and the prevalence of oral and upper gastrointestinal cancer. A different problem is the cancer treatment-caused alterations in oral microbiota which may lead to the emergence of potential pathogens and subsequent other systemic health problems to the patients. Hence clinical guidelines and recommendations have been presented to control oral microbiota in patients with malignant disease, but also in this area the scientific evidence is weak. More controlled studies are needed for further conclusion.

Attitudes and perceptions towards oral hygiene tasks among geriatric nursing home staff

OBJECTIVES

To assess attitudes and perceptions towards oral hygiene tasks among geriatric nursing home staff, before and after a dental hygiene education.

METHODOLOGY

A survey questionnaire was distributed to the nursing staff (n = 105), at a geriatric nursing home in Stockholm, Sweden.

RESULTS

The response rate to the questionnaire was 83%. A vast majority (87%) of the nursing staff considered oral hygiene tasks unpleasant. The main reason for considering oral care unpleasant was a perceived unwillingness from the residents. The perceived unwillingness from the residents among the nursing staff was reduced after the dental hygiene education (chi-square test, P = 0.02). A vast majority of the nursing staff experienced, always or sometimes, resistance from the residents towards oral care.

CONCLUSIONS

Nursing home staff members consider oral care tasks unpleasant, and frequently experience resistance from the nursing home residents towards oral care. The perceived unwillingness from the residents is reduced after an advanced dental hygiene education. Further studies are needed to evaluate the effects of education on nursing staff's attitudes and perceptions towards oral care tasks, with the overall aim of improving the oral health among older people in hospitals and nursing homes.

Need of assistance with daily oral hygiene measures among nursing home resident elderly versus the actual assistance received from the staff

The aim was to evaluate the need of assistance with daily oral hygiene measures among nursing home resident elderly versus the actual assistance received from the staff. The need of daily oral hygiene assistance was assessed descriptively for nursing home resident elderly who participated in an annual oral health screening in three geographical regions in Sweden, in the year 2008. All individuals of age ≥ 65 years were included (n = 22,453; 6,327 men; 16,126 women). The proportion of individuals in need of assistance with daily oral hygiene measures was 77.5 % (n=22,453), whereas the proportion of individuals receiving assistance with daily oral hygiene measures was 6.9 % in total (n=22,453). The proportions were largely similar in all geographical regions. There seems to be a large discrepancy between the need of assistance with daily oral hygiene measures, and the oral hygiene assistance received, among nursing home resident elderly.