Oral health and history of respiratory tract infection in frail institutionalised elders

The impact of oral diseases on respiratory health and the influence of respiratory infections on the oral microbiome

OBJECTIVE

The objective of this review is to examine the relationship between oral diseases and respiratory health, investigating how oral microbiome disruptions contribute to respiratory tract infections. Additionally, it aims to explore the impact of respiratory disease symptoms and treatments on the oral microbiome.

DATA SOURCES

The literature utilized in this review was sourced from studies focusing on the correlation between oral health and respiratory infections, spanning a period of 40 years. Various databases and scholarly sources were likely consulted to gather relevant research articles, reviews, and clinical studies.

STUDY SELECTION

This review summarizes four decades-long research, providing insights into the intricate relationship between oral and respiratory health. It delves into how oral diseases influence respiratory tract conditions and vice versa. The selection process likely involved identifying studies that addressed the interaction between oral microbiome disruptions and respiratory complications.

CONCLUSION

Oral diseases or poor oral habits have been known to increase the risk of getting respiratory infections. Modern techniques have demonstrated the relationship between oral disease and respiratory tract infections like influenza, chronic obstructive pulmonary diseases, asthma, and Pneumonia. Apart from that, the medications used to treat respiratory diseases affect oral physiological factors like the pH of saliva, and saliva flow rate, which can cause significant changes in the oral microbiome. This review provides regular oral hygiene and care that can prevent respiratory health and respiratory infections.

CLINICAL SIGNIFICANCE

Understanding the intricate relationship between oral health and respiratory infections is crucial for healthcare providers. Implementing preventive measures and promoting good oral hygiene habits can reduce respiratory tract infections and improve overall respiratory health outcomes.

Impact of Poor Oral Health on Community-Dwelling Seniors: A Scoping Review

The aim of this scoping review was to determine health-related impacts of poor oral health among community-dwelling seniors. Using MeSH terms and keywords such as elderly, general health, geriatrics, 3 electronic databases-Medline, CINAHL, and Age Line were searched. Title and abstracts were independently screened by 3 reviewers, followed by full-texts review. A total of 131 articles met our inclusion criteria, the majority of these studies were prospective cohort (77%, n = 103), and conducted in Japan (42 %, n = 55). These studies were categorized into 16 general health outcomes, with mortality (24%, n = 34), and mental health disorders (21%, n = 30) being the most common outcomes linked with poor oral health. 90% (n = 120) of the included studies reported that poor oral health in seniors can subsequently lead to a higher risk of poor general health outcomes among this population. Improving access to oral healthcare services for elderly can help not only reduce the burden of oral diseases in this population group but also address the morbidity and mortality associated with other general health diseases and conditions caused due to poor oral health. Findings from this study can help identify shortcomings in existing oral healthcare programs for elderly and develop future programs and services to improve access and utilization of oral care services by elderly.

Poor oral hygiene and dental caries predict high mortality rate in hemodialysis: a 3-year cohort study

The aim of this study was to investigate the impact of oral hygiene, periodontal diseases, and dental caries on all-cause mortality in hemodialysis. This prospective cohort study included 266 patients with end-stage renal disease who were undergoing hemodialysis. Medical interviews, blood biochemical tests, and comprehensive dental examinations including periodontal pocket examination on all teeth and dental plaque accumulation by debris index-simplified (DI-S), were performed. Survival rates were assessed at a 3-year follow-up. Overall, 207 patients were included in the longitudinal analysis, and 38 subjects died during the follow-up period. Cox proportional hazards analysis of the multivariate model demonstrated that the highest tertile of DI-S had a significantly higher risk of all-cause mortality than the lowest two tertiles after adjustment for age, sex, smoking habit, body mass index, diabetes, prior cardiovascular disease, hemodialysis vintage, high sensitivity C-reactive protein, albumin, and number of remaining teeth (hazard ratio, 3.04; 95% confidence interval, 1.50–6.17; p = 0.002). Moreover, the number of decayed teeth significantly increased the hazard ratio to 1.21 (95% confidence interval, 1.06.1.37; p = 0.003). This study suggests that accumulated dental plaque and untreated decay, but not periodontal disease, may be independently associated with all-cause mortality in patients undergoing hemodialysis.

The impact of 0.2% chlorhexidine gel on oral health and the incidence of pneumonia amongst adults with profound complex neurodisability

AIMS

Investigate the effect of toothbrushing with 0.2% chlorhexidine gel on oral health and pneumonia amongst patients with a neurodisability who are fed via percutaneous endoscopic gastrostomy.

METHOD

Forty-nine patients at the Royal Hospital for Neuro-disability were recruited to an observational study. Daily toothbrushing with 0.2% chlorhexidine gel was undertaken for 12 months by trained nursing staff. Plaque and gingival health were assessed every six weeks using the Simplified Debris Index and the Basic Periodontal Examination. The annual incidence and prevalence of episodes of pneumonia experienced by patients whilst using the chlorhexidine gel were compared to rates from the previous year.

RESULTS

Plaque levels and the proportion of patients with periodontal pocketing > 3.5 mm significantly reduced, P < .001, with chlorhexidine toothbrushing. Total number of pneumonia episodes (75-67), antibiotics administered (73-64), and radiographs taken (19 to 16) were lower in the year wherein chlorhexidine was employed, and hospitalisations dropped by 31% (16-11), but these reductions were not statistically significant. No adverse events were reported.

CONCLUSION

Daily toothbrushing with 0.2% chlorhexidine undertaken by a trained and supported nursing staff was effective in improving oral health but did not significantly affect annual rates of pneumonia amongst patients.

Relationship between Respiratory and Periodontal Health in Adults: A Case-Control Study

Aims and Objectives

The colonization of the respiratory pathogens has been found in the oral cavity. In the high-risk patients for lung infection; the risk factor is the high colonization of the respiratory pathogens in the oral cavity. The present study was performed with an aim to investigate the relationship between periodontal health and respiratory diseases.

Material and Methods

The present cross-sectional study was conducted in the individuals who were attending the outpatient department of dentistry and those who signed the informed consent to participate in the study. A total of 198 patients were included in the present study. Ninety-nine patients with respiratory diseases were included in the test group and 99 patients with normal pulmonary function were added in the control group. Spirometry was used for the confirmation of the lung diseases. We had assessed the clinical parameters such as plaque index, gingival index, loss of attachment, and community periodontal index with the help of SPSS software 15 and compared between cases and controls.

Results

The mean age of control patients were 35.12 and for respiratory patients was 43.32. There were 65 males and 34 females in case group with respiratory diseases. The controls consisted of 63 males and 36 females. The high scores for various gingival and periodontal indexes in respiratory patients confirmed more periodontal destruction with respect to that group, compared to the nonrespiratory group.

Conclusion

It is concluded that a strong association between periodontitis and chronic obstructive pulmonary disease was found. The assessment of the risk factors along with patient education regarding the risk should be done so that suitable intervention strategies can be implemented.

Association between oral health and upper respiratory tract infection among children

BACKGROUND

The oral cavity is a potential reservoir for respiratory pathogens. This longitudinal study investigated the association between upper respiratory tract infection (URI) and oral health among children.

METHODS

A total of 288 children aged 4 years were recruited. Their dental caries and oral hygiene status were clinically determined, using the dmft (decayed, missing and filled teeth) index and the Silness-Löe plaque index. Questionnaires were completed by parents to collect information on the child's socio-demographic background and URI episodes and symptoms in the following 12 months. Standard or zero-inflated negative binomial regressions were used to analyse the association between URI and both oral health indicators (dmft and plaque score).

RESULTS

Some 138 (47.9%) children had URI in 12 months, including 63 (21.9%) and 75 (26.0%) children with 1-2 episodes and ≥3 episodes, respectively. The reported URI episodes fell into two peaks, coinciding with the two influenza peaks in Hong Kong. Significantly a higher dmft was found among children without URI compared with children who had ≥3 URI episodes (1.32 vs. 0.49; P = 0.043). The number of URI episodes was inversely associated with dmft (IRR = 0.851; 95% CI: 0.766-0.945; P = 0.003). There was no significant association between the plaque score and URI (P > 0.05).

CONCLUSIONS

The children's caries experience was associated with reduced episodes of URI. Whether this inverse association is attributed to the immune response induced by dental caries is yet to be investigated.

Dental and microbiological risk factors for hospital-acquired pneumonia in non-ventilated older patients

Hospital acquired pneumonia (HAP) is often fatal in older patients. The mouth is the main reservoir of infection and studies have suggested that oral hygiene interventions may prevent HAP. The aim of this study was to investigate associations between HAP and preceding a) heavy dental plaque and b) oral carriage of potential respiratory pathogens in older patients with lower limb fracture to determine the target for intervention studies.

Community-acquired pneumonia among smokers

Recent studies have left absolutely no doubt that tobacco increases susceptibility to bacterial lung infection, even in passive smokers. This relationship also shows a dose-response effect, since the risk reduces spectacularly 10 years after giving up smoking, returning to the level of non-smokers. Streptococcus pneumoniae is the causative microorganism responsible for community-acquired pneumonia (CAP) most frequently associated with smoking, particularly in invasive pneumococcal disease and septic shock. It is not clear how it acts on the progress of pneumonia, but there is evidence to suggest that the prognosis for pneumococcal pneumonia is worse. In CAP caused by Legionella pneumophila, it has also been observed that smoking is the most important risk factor, with the risk rising 121% for each pack of cigarettes smoked a day. Tobacco use may also favor diseases that are also known risk factors for CAP, such as periodontal disease and upper respiratory viral infections. By way of prevention, while giving up smoking should always be proposed, the use of the pneumococcal vaccine is also recommended, regardless of the presence of other comorbidities.

Chlorhexidine decreases the risk of ventilator-associated pneumonia in intensive care unit patients: a randomized clinical trial

BACKGROUND AND OBJECTIVE

The aim was to evaluate whether oral swabbing with 0.2% chlorhexidine gluconate (CHX) decreases the risk of ventilator-associated pneumonia (VAP) in intensive care unit (ICU) patients.

MATERIAL AND METHODS

Sixty-one dentate patients scheduled for invasive mechanical ventilation for at least 48 h were included in this randomized, double-blind, controlled study. As these patients were variably incapacitated, oral care was provided by swabbing the oral mucosa four times/d with CHX in the CHX group (29 patients) and with saline in the control group (32 patients). Clinical periodontal measurements were recorded, and lower-respiratory-tract specimens were obtained for microbiological analysis on admission and when VAP was suspected. Pathogens were identified by quantifying colonies using standard culture techniques.

RESULTS

Ventilator-associated pneumonia developed in 34/61 patients (55.7%) within 6.8 d. The VAP development rate was significantly higher in the control group than in the CHX group (68.8% vs. 41.4%, respectively; p = 0.03) with an odds ratio of 3.12 (95% confidence interval = 1.09-8.91). Acinetobacter baumannii was the most common pathogen (64.7%) of all species identified. There were no significant differences between the two groups in clinical periodontal measurements, VAP development time, pathogens detected or mortality rate.

CONCLUSION

The finding of the present study, that oral care with CHX swabbing reduces the risk of VAP development in mechanically ventilated patients, strongly supports its use in ICUs and indeed the importance of adequate oral hygiene in preventing medical complications.

Implications of oral biofilms in medically at risk persons

There is the need to understand the composition of oral biofilms so that appropriate preventive and treatment regimens, including using appropriate antimicrobials, can be developed further. Additionally, when the systemic effects from specific microorganisms in oral biofilms are better understood, more targeted preventive treatment options may be recommended for persons at high risk for potential systemic diseases such as cardiovascular disease, and for aspiration pneumonia. Hence, the possible association between periodontopathic microorganisms, and also between cariogenic microorganisms in high caries risk persons, and systemic diseases requires further research involving metagenomic and large well-designed clinical studies. Effective preventive oral care is important for reducing potential systemic diseases.

Porphyromonas gingivalis enzymes enhance infection with human metapneumovirus in vitro

Relatively recently discovered, human metapneumovirus (HMPV) is a human pathogen with worldwide prevalence, accounting for a substantial percentage of respiratory tract diseases. Concurrent viral and bacterial infections enable intricate mechanisms of cooperation between pathogens, which complicate the symptoms and outcome of the disease. Such bilateral interactions are based on the modulation of bacterial growth on epithelium pathologically altered during viral illness and the modulation of immune responses, as well as the enhancement of virus replication by bacterial virulence factors. This study showed that proteases produced by Porphyromonas gingivalis, a Gram-negative bacterium implicated in the development of periodontitis, named gingipains, facilitated HMPV replication in LLC-MK2 cells and may contribute to HMPV pathogenicity in patients with periodontitis. Gingipains at low nanomolar concentrations enabled HMPV replication and allowed virus propagation in vitro. In contrast to previously published data for influenza virus, however, Staphylococcus aureus proteases and human neutrophil elastase did not affect virus replication.

Evidence-based guidelines for the care and maintenance of complete dentures: a publication of the American College of Prosthodontists

The current rates of edentulism have been estimated to be between 7% and 69% of the adult population internationally. In the United States, while the incidence of edentulism continues to decline, rapid population growth coupled with current economic conditions suggest that edentulism and conventional denture use will continue at current or higher numbers. Unfortunately, evidence-based guidelines for the care and maintenance of removable complete denture prostheses do not exist. In 2009, the American College of Prosthodontists (ACP) formed a task force to establish evidence-based guidelines for the care and maintenance of complete dentures. The task force comprised members of the ACP, the Academy of General Dentistry, American Dental Association (ADA) Council on Scientific Affairs, the American Dental Hygienists' Association, the National Association of Dental Laboratories, and representatives from GlaxoSmithKline Consumer Healthcare. The review process included the assessment of over 300 abstracts and selection of over 100 articles meeting inclusion criteria of this review. The task force reviewed synopses of the literature and formulated 15 evidence-based guidelines for denture care and maintenance. These guidelines were reviewed by clinical experts from the participating organizations and were published in February 2011 issue of The Journal of the American Dental Association for widespread distribution to the dental community. These guidelines reflect the views of the task force.

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.

Association between respiratory disease in hospitalized patients and periodontal disease: a cross-sectional study

BACKGROUND

Recent research indicated that periodontal infection may worsen systemic diseases, including pulmonary disease. Respiratory infections, such as pneumonia and the exacerbation of chronic obstructive pulmonary disease, involve the aspiration of bacteria from the oropharynx into the lower respiratory tract.

METHODS

A group of 100 cases (hospitalized patients with respiratory disease) and a group of 100 age-, sex-, and race-matched outpatient controls (systemically healthy patients from the outpatient clinic, Department of Periodontics, Government Dental College and Hospital, Calicut, Kerala, India) were selected for the study. Standardized measures of oral health that were performed and compared included the gingival index (GI), plaque index (PI), and simplified oral hygiene index (OHI). Data regarding probing depths and clinical attachment levels (CALs) were recorded at four sites per tooth and compared statistically. The χ(2) and Student t tests were used for statistical analyses.

RESULTS

The comparison of study-population demographics on the basis of age, sex, education, and income showed no significant differences between groups. Patients with respiratory disease had significantly greater poor periodontal health (OHI and PI), gingival inflammation (GI), deeper pockets, and CALs compared to controls. In the case group, patients with a low income were 4.4 times more prone to periodontal disease compared to high-income patients. Smokers had significantly higher CALs compared to non-smokers in the control group.

CONCLUSION

The findings of the present analysis support an association between respiratory and periodontal disease.

Oral health, general health, and quality of life in older people

The purpose of this report is to review the interrelationship between poor oral health conditions of older people and general health. The impact of poor oral health on quality of life (QOL) is analyzed, and the implications for public health intervention and oral health care are discussed. Findings from the current research may lead to the following conclusions: The available scientific evidence is particularly strong for a direct relationship between diabetes and periodontal disease; the direct relationship between periodontal disease and cardiovascular disease is less convincing. General and associated oral health conditions have a direct influence on elder people's QOL and lifestyle. The growing number of elderly people challenges health authorities in most countries. The evidence on oral health-general health relationships is particularly important to WHO in its effort to strengthen integrated oral health promotion and disease prevention around the globe.

[The guideline Oral Health Care for dependent residents in long term care facilities, 2007: dire necessity!]

The oral health status of residents in Dutch nursing homes is rather poor, especially of those depending on caregivers for their oral health care. Moreover, when care dependency is rising, the provision of good oral health care becomes more difficult. With more elderly people still having (parts of) their natural teeth, the need for good oral health care is increasing even more. Therefore a specific guideline was developed. The ultimate aim of the guideline "Oral health care for dependent residents in long term care facilities" is to improve the oral health of nursing home residents. Oral health care needs to be incorporated in daily nursing home care routine and in the integral care plan of every resident. Attention is given to the importance of an adequate implementation of this guideline as well as to the necessity of research evaluating the effects of it's implementation.

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

The objective of this study was to investigate the preventive effect of oral hygiene on pneumonia and respiratory tract infection, focusing on elderly people in hospitals and nursing homes, by systematically reviewing effect estimates and methodological quality of randomized controlled trials (RCTs) and to provide an overview of additional clinical studies in this area. Literature searches were conducted in the Medline database, the Cochrane library databases, and by hand-searching reference lists. Included publications were analyzed for intervention (or topic) studied, main conclusions, strength of evidence, and study design. RCTs were further analyzed for effect magnitudes and methodological details. Absolute risk reductions (ARRs) and numbers needed to treat (NNTs) were calculated. Fifteen publications fulfilled the inclusion criteria. There was a wide variation in the design and quality of the studies included. The RCTs revealed positive preventive effects of oral hygiene on pneumonia and respiratory tract infection in hospitalized elderly people and elderly nursing home residents, with ARRs from 6.6% to 11.7% and NNTs from 8.6 to 15.3 individuals. The non-RCT studies contributed to inconclusive evidence on the association and correlation between oral hygiene and pneumonia or respiratory tract infection in elderly people. Mechanical oral hygiene has a preventive effect on mortality from pneumonia, and non-fatal pneumonia in hospitalized elderly people and elderly nursing home residents. Approximately one in 10 cases of death from pneumonia in elderly nursing home residents may be prevented by improving oral hygiene. Future research in this area should be focused on high-quality RCTs with appropriate sample size calculations.

A new method of assessing aerosolized bacteria generated during orthodontic debonding procedures

INTRODUCTION

The main objective of this study was to assess the efficacy of a new and innovative method of harvesting bacteria that are aerosolized during orthodontic debonding. Additionally, the protection efficacy of several commercially available masks from such aerosols was assessed in a pilot study.

METHODS

Twenty-six subjects were debonded during aerosol sampling, by using an innovative collection system to harvest bonding dust liberated during debonding. Dark-field microscopy, gram-stain microscopy, and chemical identification were used to determine speciation of the collected aerosol from 23 subjects. Three additional subjects were used to test 3 commercial dental or protective masks to determine whether they provide effective protection from the aerosol.

RESULTS

Twenty-one species of oral bacteria were identified by the new sampling technique. Two of the 3 masks that were tested offered no protection against the aerosolized bacteria.

CONCLUSIONS

A new and effective method for collecting airborne bacteria is presented. Some conventional dental masks offer no protection from aerosolized organisms liberated during debonding procedures. Further assessment of mask efficacy is ongoing.

The stomatognathic system in the elderly. Useful information for the medical practitioner

Aging per se has a small effect on oral tissues and functions, and most changes are secondary to extrinsic factors. The most common oral diseases in the elderly are increased tooth loss due to periodontal disease and dental caries, and oral precancer/cancer. There are many general, medical and socioeconomic factors related to dental disease (ie, disease, medications, cost, educational background, social class). Retaining less than 20 teeth is related to chewing difficulties. Tooth loss and the associated reduced masticatory performance lead to a diet poor in fibers, rich in saturated fat and cholesterols, related to cardiovascular disease, stroke, and gastrointestinal cancer. The presence of occlusal tooth contacts is also important for swallowing. Xerostomia is common in the elderly, causing pain and discomfort, and is usually related to disease and medication. Oral health parameters (ie, periodontal disease, tooth loss, poor oral hygiene) have also been related to cardiovascular disease, diabetes, bacterial pneumonia, and increased mortality, but the results are not yet conclusive, because of the many confounding factors. Oral health affects quality of life of the elderly, because of its impact on eating, comfort, appearance and socializing. On the other hand, impaired general condition deteriorates oral condition. It is therefore important for the medical practitioner to exchange information and cooperate with a dentist in order to improve patient care.

Oral biofilms, periodontitis, and pulmonary infections

Bacteria from the oral biofilms may be aspirated into the respiratory tract to influence the initiation and progression of systemic infectious conditions such as pneumonia. Oral bacteria, poor oral hygiene, and periodontitis seem to influence the incidence of pulmonary infections, especially nosocomial pneumonia episodes in high-risk subjects. Improved oral hygiene has been shown to reduce the occurrence of nosocomial pneumonia, both in mechanically-ventilated hospital patients and non-ventilated nursing home residents. It appears that oral colonization by potential respiratory pathogens, possibly fostered by periodontitis, and possibly by bacteria specific to the oral cavity or to periodontal diseases contribute to pulmonary infections. Thus, oral hygiene will assume an even more important role in the care of high-risk subjects--patients in the hospital intensive care and the elderly. The present paper critically reviews the recent literature on the effect of oral biofilms and periodontitis on pneumonia.

Systematic Review of the Association Between Respiratory Diseases and Oral Health

BACKGROUND

The purpose of this review was to investigate evidence for a possible etiological association between oral health and pneumonia or other respiratory diseases.

METHODS

The following data sources were used: Ovid MEDLINE (In-Process & Other Non-Indexed Citations, Daily Update, and OLDMEDLINE); Cumulative Index to Nursing & Allied Health Literature; Evidence Based Medicine of Cochrane Central Register of Controlled Trials; Cochrane Database of Systematic Reviews; Database of Abstracts of Reviews of Effects; EMBASE; Health and Psychosocial Instruments; HealthSTAR; International Pharmaceutical Abstracts; PubMed; and Google Scholar from the earliest record until July 2005. Studies were selected from randomized controlled clinical trials and longitudinal, cohort, case-control, and epidemiological studies. Searches were limited to English language and human studies.

RESULTS

A total of 728 articles were searched for relevancy, determined by article title, abstract, and full copy, resulting in a yield of 19 studies that met our inclusion criteria. These articles were read and scored independently by the reviewers to obtain the evidence for this review: 1) the potential risk factors for pneumonia were identified as the presence of cariogenic and periodontal pathogens, dental decay, and poor oral hygiene in five studies; 2) a weak association between periodontal disease and chronic obstructive pulmonary disease (COPD) was identified in four poor to fair studies; and 3) 10 studies were retained providing evidence that interventions aiming to improve oral health reduced the progression or occurrence of pneumonia.

CONCLUSIONS

1) There is fair evidence (II-2, grade B recommendation) of an association of pneumonia with oral health (odds ratio [OR]=1.2 to 9.6 depending on oral health indicators). 2) There is poor evidence of a weak association (OR<2.0) between COPD and oral health (II-2/3, grade C recommendation). 3) There is good evidence (I, grade A recommendation) that improved oral hygiene and frequent professional oral health care reduces the progression or occurrence of respiratory diseases among high-risk elderly adults living in nursing homes and especially those in intensive care units (ICUs) (number needed to treat [NNT]=2 to 16; relative risk reduction [RRR]=34% to 83%).

Transient oral microflora in Greeks attending day centres for the elderly and residents in homes for the elderly

OBJECTIVE

To examine the isolation frequency and the carriage of yeasts, Enterobacteriaceae, Staphylococcus and Enterococcus species in oral samples from elderly Greeks living alone or in institutions.

BACKGROUND

Ageing may promote changes in the oral ecosystem, which lead to colonisation of the mouth by microbes found less commonly or only transiently in younger subjects. Previous studies indicate a geographical variation in the isolation frequency of such bacteria in elderly populations.

MATERIALS AND METHODS

Medical and dental records were obtained from 66 attenders at elderly people's day centres (EPDC), and 82 residents of elderly people's homes (EPH), 66-95 years old. Mucosa smear samples were cultured on appropriate media for enumeration of the above species. Microbial identification was performed by conventional microbiological tests. The results were analysed using the Multiple Correspondence Analysis (MCA), ANOVA and other traditional statistical tests.

RESULTS

No statistically significant association was found between the place of residence and the wearing of dentures. The isolation frequencies of Staphylococcus aureus, Enterococcus and Enterobacteriaceae species were 21.6, 20.3 and 7.4% respectively. MCA, and further statistical analysis, revealed that the place of residence affected the isolation frequency of years (54.9% in EPH vs. 37.9% in EPDC). Moreover, ANOVA showed that living in EPH increased the carriage of yeasts.

CONCLUSIONS

Elderly Greeks exhibit a moderate to high oral carriage of transient bacteria compared with other elderly populations. Living in EPH seems to increase both the isolation frequency and carriage of yeasts.

Systemic effects of periodontal diseases

A number of studies suggest an association between periodontal disease and cardiovascular disease, pulmonary disease, diabetes,and pregnancy complications. Presently, the data must be regarded as preliminary. Additional large-scale longitudinal epidemiologic and interventional studies are necessary to validate these associations and to determine whether the associations are causal. The goal of this article is to review the history of this concept, describe the biologically plausible circumstances that may underlie these potential associations, and provide a summary of the published literature that supports or refutes them.

The advantages of occupational therapy in oral hygiene measures for institutionalised elderly adults

OBJECTIVE

To investigate a new method in teaching and supervising tooth and denture brushing activities by employing occupational therapy techniques.

MATERIALS AND METHODS

Sixty-one residents, 44 women and 17 men, with an average age of 85.7 +/- 6.6 years (range 72-97 years) living in a Long-Term Care home (LTC) in Geneva were enrolled in a randomised controlled trial. They were divided at random into experimental (EG) and control groups (CG) with matched age and sex distribution. Two subjects passed away during the 3-month experimental period. Following medical history, plaque scores and tooth brushing habits were evaluated within the context of a comprehensive clinical assessment. Furthermore, a Mini Mental State and a vision test were taken. Based on the results of these health assessments both the EG and the CG were divided into an 'assisted' (IA) and an 'independent' (II) subgroup. In the EG, tooth brushing was initially taught and in the IA monitored and re-educated once a week by an occupational therapist. In contrast, the CG-IA group received a weekly placebo activity such as manicure by the same person.

RESULTS

From the individual movements taught and monitored by the occupational therapist, opening a tube of toothpaste (n.s.) and denture brushing (p < 0.05) were performed more independently after 3 months. Both the occupational therapy and the placebo activity led to a significant improvement in oral (p < 0.01 and 0.05) and in denture hygiene (p < 0.001 and 0.05). From all participants, the EG-IA subgroup presented the most significant amelioration in plaque (p < 0.01) and denture hygiene scores (p < 0.001). This group consisted mostly of subjects with an impaired cognitive state.

CONCLUSIONS

Despite the marked placebo effect, the results indicate that occupational therapy is particularly useful to improve the oral and denture hygiene in dependent and cognitively impaired LTC residents and may promote their autonomy in the execution of activities of daily life such as denture brushing.

Oral hygiene and oral symptoms among the elderly in long-term care

Dental teams examined 1910 elderly adults living in long-term care settings (1358 institutionalized, 552 homebound) from all 19 counties in Norway to document oral hygiene, oral symptoms and ability to receive dental treatment. The Mucosal-Plaque Score (MPS) was used to assess oral status. The MPS was significantly better in women than in men, in individuals with dentures than in those with any remaining teeth, and in people who were homebound rather than those who lived in institutions. The MPS did not differ between age groups or geographic regions. According to the Treatment Ability Index, nearly a quarter of the sample was able to receive comprehensive dental care. Reports of "any oral symptom" and "eating/chewing problems" decreased with age and were most prevalent for individuals who had dentures. The MPS had only slight impact on oral symptoms, chewing ability and dry mouth (p > 0.05). Dry mouth was found in 16.9% and was most prevalent in individuals with dentures.

Associations Between Periodontal Disease and Risk for Nosocomial Bacterial Pneumonia and Chronic Obstructive Pulmonary Disease. A Systematic Review

BACKGROUND

Several recent studies provide evidence that the oral cavity may influence the initiation and/or the progression of lung diseases such as pneumonia and chronic obstructive pulmonary disease (COPD).

RATIONALE

Studies have shown that poor oral hygiene and periodontal disease may foster colonization of the oropharyngeal region by respiratory pathogens, particularly in hospital or nursing home patients. If aspirated, these pathogens can cause pneumonia, one of the most common respiratory infections, especially in institutionalized subjects. Other cross-sectional epidemiologic studies point to an association between periodontal disease and COPD. This systematic review examines the literature to determine if interventions that improve oral hygiene reduce the rate of pneumonia in high-risk populations.

FOCUSED QUESTION

Do periodontal diseases or other indicators of poor oral health influence the initiation/progression of pneumonia or other lung diseases?

SEARCH PROTOCOL

MEDLINE, pre-MEDLINE, MEDLINE Daily Update, and the Cochrane Controlled Trials Register were searched to identify published studies that related variables associated with pneumonia and other lung disease to periodontal disease. Searches were performed for articles published in English from 1966 through March 2002.

INCLUSION CRITERIA

Randomized controlled clinical trials (RCTs), longitudinal, cohort, and case-control studies were included. Study populations included patients with any form of pneumonia or chronic obstructive pulmonary disease (COPD) and periodontal disease, as measured by assessments of gingival inflammation, probing depth, clinical attachment level, and/or radiographic bone loss, or oral hygiene indices.

EXCLUSION CRITERIA

Limited to studies of humans.

DATA COLLECTION AND ANALYSIS

The summary statistics used to analyze the RCTs included weighted mean differences in rates of disease between control and intervention groups. For cohort studies that measured differences in rates of disease between groups with and without oral disease, weighted mean differences, relative risks, or odds ratios were compared. A meta-analysis was performed on the 5 intervention studies to determine the relationship between oral hygiene intervention and rate of pneumonia in institutionalized patients.

MAIN RESULTS

Of the initial 1,688 studies identified, 36 satisfied all inclusion criteria and were read. Of these, 21 (11 case-control and cohort studies [study population 1,413] and 9 RCTs [study population 1,759]) were included in the analysis. 1. A variety of oral interventions improving oral hygiene through mechanical and/or topical chemical disinfection or antibiotics reduced the incidence of nosocomial pneumonia by an average of 40%. 2. Several studies demonstrated a potential association between periodontal disease and COPD.

REVIEWERS' CONCLUSIONS

1. Oral colonization by respiratory pathogens, fostered by poor oral hygiene and periodontal diseases, appears to be associated with nosocomial pneumonia. 2. Additional large-scale RCTs are warranted to provide the medical community with further evidence to institute effective oral hygiene procedures in high-risk patients to prevent nosocomial pneumonia. 3. The results associating periodontal disease and COPD are preliminary and large-scale longitudinal and epidemiologic and RCTs are needed.

Respiratory infection: how important is oral health?

The oral cavity has long been considered a potential reservoir for respiratory pathogens. Recently, there has been a renewed interest in the relation between oral flora and respiratory infection among "at-risk" patients such as patients from intensive care units or frail older adults. The mechanisms of infection could be colonization of the oral biofilm by respiratory pathogens followed by aspiration. More recent hypotheses relate to the presence in saliva of enzymes and cytokines associated with oral pathogens, and that could modulate the colonization of the respiratory tract or promote infection by respiratory pathogens. It is the aim of this paper to review the recent literature on this topic.

Bronchopneumonia and oral health in hospitalized older patients. A pilot study

AIMS

To correlate microbial findings obtained by bronchoalveolar lavage in pneumonia patients with the clinical situation of the oral cavity.

METHOD

Quantitative aerobic and anaerobic cultures were carried out in 150 ml samples of bronchoalveolar lavage (BAL) obtained by means of an endoscope (Video Endoscope Pentax) inserted per os in the infected bronchus.

MATERIAL

Twenty consecutive patients with a tentative clinical diagnosis of bronchopneumonia in whom BAL was carried out for diagnostic purposes. A clinical evaluation of the oral health status (oral hygiene, caries, periodontal diseases) was subsequently carried out.

RESULTS

In seven edentulous subjects wearing complete dentures the culture of anaerobic microorganisms was negative or yielding less than 100 cfu/ml BAL. Two patients yielded high counts of S. aureus and one high counts of P. aeruginosa. In the 13 subjects with natural teeth left one showed high counts of Veillonella spp. (anaerobic) + P. aeruginosa, one high counts of Veillonella spp. + S. aureus, one high counts of P. aeruginosa + S. aureus and one high counts of E. coli. These four subjects showed poor oral hygiene, periodontal pockets and a BAL microflora consistent with periodontal pathology.

CONCLUSION

The results of this pilot study suggest that microorganisms of denture plaque or associated with periodontal diseases may give rise to aspiration pneumonia in susceptible individuals.

Oral care reduces pneumonia in older patients in nursing homes

OBJECTIVES

Aspiration of oral secretions and their bacteria is increasingly being recognized as an important factor in pneumonia. We investigated whether oral care lowers the frequency of pneumonia in institutionalized older people.

DESIGN

Survey.

SETTING

Eleven nursing homes in Japan.

PARTICIPANTS

Four hundred seventeen patients randomly assigned to an oral care group or a no oral care group.

INTERVENTION

Nurses or caregivers cleaned the patients' teeth by toothbrush after each meal. Swabbing with povidone iodine was additionally used in some cases. Dentists or dental hygienists provided professional care once a week.

MEASUREMENTS

Pneumonia, febrile days, death from pneumonia, activities of daily living, and cognitive functions.

RESULTS

During follow-up, pneumonia, febrile days, and death from pneumonia decreased significantly in patients with oral care. Oral care was beneficial in edentate and dentate patients. Activities of daily living and cognitive functions showed a tendency to improve with oral care.

CONCLUSION

We suggest that oral care may be useful in preventing pneumonia in older patients in nursing homes.

Dental status and satisfaction with oral function in a sample of community-dwelling elderly people in Japan

The purpose of this study was to determine the influence of dental status on oral function and satisfaction among a group of independently living elderly persons in an urban area of Japan. The study sample consisted of participants of the Senior Citizens' College from 1995 to 1999. Their dental status and oral satisfaction were measured by a questionnaire. The number of usable questionnaires was 3967, or 80.8% of the total sample. The mean age of the subjects was 66.5+/-4.3 years, and 52.2% were male. Twenty-nine percent of them had a natural dentition, and 7.0% were edentulous in both jaws. The prevalence of edentulism in the study sample was significantly lower (p < 0.01) than that for the national survey. Overall, 66.4% of the subjects were satisfied with their ability to chew, 56.2% with the appearance of their teeth, 63.1% with their ability to speak clearly, and 76.5% with their ability to taste food. For complete-denture wearers, the greatest dissatisfaction was with speech (28.5%); however, for the RPD wearers, it was with chewing ability (21.7%). Sixty-one percent of complete-denture wearers reported that they were satisfied with their chewing ability, but only 11% of them could eat all three of the evaluated foods without difficulty. The multiple stepwise logistic regression analyses showed that both dental status and self-assessed general health had a significant association with dissatisfaction with all four oral functions and self-assessed impairment of chewing ability. There were significant associations between the elderly subjects' dental status and oral function.

The relationship between infections and chronic respiratory diseases: an overview

This paper's goal is to review the relationship between infections and chronic respiratory disease, with particular reference to periodontal disease. The link between oral diseases in general, periodontal disease, and respiratory disease remains somewhat controversial. However, with cooperation between dentistry and medicine, the nature of the connection between dental and medical pathology can be better defined. An overview of respiratory disease and some of the factors that can contribute to respiratory infection is presented below, with special reference to infections related to aspiration.

Oral microbial flora and oral malodour of the institutionalised elderly in Japan

OBJECTIVES

To determine the oral health status, especially the level of oral microbial flora and oral malodour, of institutionalised elderly people compared with non-institutionalised elderly people.

SETTING

Three institutions and numerous private homes.

SUBJECTS

56 institutionalised and 56 non-institutionalised elderly people.

MAIN OUTCOME MEASURES

Institutionalised elderly people had higher levels of candida, staphylococci, and oral malodour.

RESULTS

Institutionalised elderly people had a higher level of candida in denture wearers, and a higher level of staphylococci and oral malodour compared with the non-institutionalised elderly.

CONCLUSION

The institutionalised elderly have a higher risk of opportunistic infections and oral health care should be improved to protect them from these infections and to reduce oral malodour.

Nutrition and oral health

Reduced chewing function in community-dwelling older people with adequate general health is linked to having fewer than 20 teeth present or to wearing removable dentures. By chewing for longer periods of time or swallowing larger food particles they are normally able to compensate for the impaired function. The masticatory function can be restored by adequate prosthetic therapy, which results in increased activity of the masticatory muscles during chewing and reduces the chewing time and the number of chewing strokes until swallowing. In frail or dependent elderly people undernutrition is prevalent because of health problems, reduced appetite and poor quality of life. Poor oral health and xerostomia are often associated with a reduced body mass index and serum albumin level and the avoidance of difficult-to-chew foods. Maintenance or re-establishment of masticatory function is an integral part of the medical health care of these patients, with the aim of improving their nutritional status and quality of life.

Oral clearance and pathogenic oropharyngeal colonization in the elderly

The elderly have an increased incidence of oropharyngeal colonization with respiratory pathogens, a well-known risk factor for the development of pneumonia. Changes in the oral milieu may occur secondary to decreased salivary production and abnormalities in swallowing. These abnormalities, common in the elderly, may result in impaired clearance of organisms, allowing pathogenic colonization. To test this hypothesis, we performed a prospective cross-sectional analysis of 75 elderly institutionalized patients and measured oral clearance using (99m)Tc-human serum albumin (HSA) administered to the oropharynx. Oropharyngeal cultures, salivary cell populations, elastase activity, and clinical parameters were measured simultaneously. Retention of radiolabel ranged from 100% to 2.3% over 120 min of observation. Clearance in the oropharynx was significantly decreased in those patients who had oropharyngeal colonization with gram-negative bacilli (GNB), Staphylococcus aureus (SA), or yeast compared with those demonstrating normal flora by 95% confidence intervals. Decreased clearance was also seen in patients on antidepressants by 95% confidence levels. The absolute number of salivary lymphocytes/ml and buccal cells/ml was increased in colonized patients versus noncolonized persons (mean +/- SEM, 128 x 10(3) +/- 49 x 10(3), 25.4 +/- 11.6 x 10(3)). Elastase activity was elevated in patients who had GNB compared with patients without GNB (mean +/- SEM, 10.6 nM +/- 5.7, versus 2.2 nM +/- 1.2, p = 0.036). We conclude that a decrease in salivary clearance of potentially pathogenic organisms may be a major risk factor for the development of colonization in the elderly.

Variation in nosocomial infection prevalence according to patient care setting:a hospital-wide survey

A study was performed to estimate the prevalence of nosocomial infections (NI) and assess differences between medical care settings in one hospital complex. A seven-day period-prevalence survey was conducted in May 1998 in a large primary and tertiary healthcare centre in Geneva, Switzerland, that included all patients in acute, sub-acute and chronic care settings. Variables included demography, exposure to invasive devices and antibiotics, surgical history, and patients' localization. Overall prevalence of NI was 11.3% (acute, 8.4%; sub-acute, 11.4%; chronic care setting, 16.4%) in the 1928 patients studied, and ranged from 0% in ophthalmology to 23% in critical care units. Odds of infection in sub-acute and chronic care settings were significantly higher than in the acute care setting even after adjustment for case-mix [OR, 2.59; 95% confidence interval (CI(95)) 1.53-4.41; and OR, 2.34; Cl(95)1.38-3.95, respectively]. As a distinct group, patients in the geriatric location (belonging to the sub-acute care setting) showed a significant proportion of urinary (39%) and respiratory (21%) tract infections, contrasting with a relatively low exposure to urinary catheters (6.1%) and orotracheal intubation (0%). In conclusion, sub-acute and chronic care settings are associated with high infection prevalence even after case-mix adjustment. Prevalence studies are an easy surveillance tool that can be exploited further by analysing data according to hospital care settings to identify high-risk areas.