Implications of oral infections on systemic diseases in the institutionalized elderly with a special focus on pneumonia

Validation of a noninvasive aMMP‐8 point‐of‐care diagnostic methodology in COVID‐19 patients with periodontal disease

Objectives

The aim of this study was to validate an active matrix metalloproteinase (MMP‐8) point‐of‐care diagnostic tool in COVID‐19 patients with periodontal disease.

Subjects, Materials, and Methods

Seventy‐two COVID‐19‐positive and 30 COVID‐19‐negative subjects were enrolled in the study. Demographic data were recorded, periodontal examination carried out, and chairside tests run for evaluating the expression of active MMP‐8 (aMMP‐8) in the site with maximum periodontal breakdown via gingival crevicular fluid sampling as well as via a mouth rinse‐based kit for general disease activity. In COVID‐19‐positive patients, the kits were run again once the patients turned COVID‐19 negative.

Results

The overall (n = 102) sensitivity/specificity of the mouthrinse‐based kits to detect periodontal disease was 79.41%/36.76% and that of site‐specific kits was 64.71%/55.88% while adjusting for age, gender, and smoking status increased the sensitivity and specificity (82.35%/76.47% and 73.53%/88.24, respectively). Receiver operating characteristic (ROC) analysis for the adjusted model revealed very good area under the ROC curve 0.746–0.869 (p < .001) and 0.740–0.872 (p < .001) (the aMMP‐8 mouth rinse and site‐specific kits, respectively). No statistically significant difference was observed in the distribution of results of aMMP‐8 mouth rinse test (p = .302) and aMMP‐8 site‐specific test (p = .189) once the subjects recovered from COVID‐19.

Conclusions

The findings of the present study support the aMMP‐8 point‐of‐care testing (PoCT) kits as screening tools for periodontitis in COVID‐19 patients. The overall screening accuracy can be further increased by utilizing adjunctively risk factors of periodontitis. The reported noninvasive, user‐friendly, and objective PoCT diagnostic methodology may provide a way of stratifying risk groups, deciding upon referrals, and in the institution of diligent oral hygiene regimens.

A cross-sectional survey to study the relationship of periodontal disease with cardiovascular disease, respiratory disease, and diabetes mellitus

BACKGROUND

Periodontal deterioration has been reported to be associated with systemic diseases such as cardiovascular disease (CVD), diabetes mellitus, respiratory disease, liver cirrhosis, bacterial pneumonia, nutritional deficiencies, and adverse pregnancy outcomes.

AIM

The present study assessed the periodontal disease among patients with systemic conditions such as diabetes, CVD, and respiratory disease.

MATERIALS AND METHODS

The study population consisted of 220 patients each of CVD, respiratory disease, and diabetes mellitus, making a total of 660 patients in the systemic disease group. A control group of 340 subjects were also included in the study for comparison purpose. The periodontal status of the patients with these confirmed medical conditions was assessed using the community periodontal index of treatment needs (CPITNs) index.

RESULTS

The prevalence of CPITN code 4 was found to be greater among the patients with respiratory disease whereas the mean number of sextants with score 4 was found to be greater among the patients with diabetes mellitus and CVD. The treatment need 0 was found to be more among the controls (1.18%) whereas the treatment need 1, 2, and 3 were more among the patients with respiratory disease (100%, 97.73%, and 54.8%), diabetes mellitus (100%, 100% and 46.4%), and CVD (100%, 97.73%, and 38.1%), in comparison to the controls (6.18%).

CONCLUSION

From the findings of the present study, it can be concluded that diabetes mellitus, CVD, and respiratory disease are associated with a higher severity of periodontal disease.

Systemic manifestations of oral diseases

The oral cavity is the site of much infectious and inflammatory disease which has been associated with systemic diseases such as diabetes, cardiovascular disease and pre-term low births. This article emphasizes on the oral-systemic disease connection which is now a rapidly advancing area of research. The possible systemic diseases which arise from oral microorganisms are hereby focused.

Time-related increase of staphylococci, Enterobacteriaceae and yeasts in the oral cavities of comatose patients

BACKGROUND/PURPOSE

The composition of oral microbiota in comatose patients remains uncertain. Some pulmonary pathogens may be found in dental biofilms or as part of the saliva microbiota. It is supposed that some pneumopathogenic microorganisms may overgrow in the mouths of comatose patients and spread to their lungs.

METHODS

The oral colonization dynamics of staphylococci, Enterobacteriaceae and yeasts in nine comatose patients (group 1), and in 12 conscious patients that brushed their teeth at least twice a day (group 2) was evaluated. Both groups were followed up for 7 days after hospitalization. Daily samples of saliva were obtained, dispersed and plated on selective culture media and colony forming units of each microbial group were obtained.

RESULTS

For patients in group 1, the counts of total viable bacteria, staphylococci, Enterobacteriaceae and yeasts progressively increased in a time-dependant manner. For the conscious patients of group 2, there was no increase.

CONCLUSION

It would appear that concomitant consciousness and brushing teeth are determinants in controlling the selected pneumopathogen counts in resting saliva. The increase in microbial counts in comatose patients is understandable because these microorganisms could spread to the lungs.

Opportunistic respiratory pathogens in the oral cavity of the elderly

The oral cavity of the hospitalized or bedridden elderly is often a reservoir for opportunistic pathogens associated with respiratory diseases. Commensal flora and the host interact in a balanced fashion and oral infections are considered to appear following an imbalance in the oral resident microbiota, leading to the emergence of potentially pathogenic bacteria. The definition of the process involved in colonization by opportunistic respiratory pathogens needs to elucidate the factors responsible for the transition of the microbiota from commensal to pathogenic flora. The regulatory factors influencing the oral ecosystem can be divided into three major categories: the host defense system, commensal bacteria, and external pathogens. In this article, we review the profile of these categories including the intricate cellular interaction between immune factors and commensal bacteria and the disturbance in homeostasis in the oral cavity of hospitalized or bedridden elderly, which facilitates oral colonization by opportunistic respiratory pathogens.

A importância da saúde bucal na ótica de pacientes hospitalizados

A percepção da condição bucal é um importante indicador de saúde, pois sintetiza a condição real de saúde, as respostas subjetivas, os valores e as expectativas culturais. O estudo avaliou a importância da saúde bucal segundo a percepção de pacientes internados em um hospital da cidade de Araçatuba (SP). Foi aplicado um questionário semi-estruturado para a coleta de dados e utilizado para análise estatística o programa Epi Info 2000. Os resultados mostraram que metade dos pacientes haviam realizado a última visita ao cirurgião-dentista em um período compreendido entre seis a doze meses devido a problemas periodontais (35%) e cárie dentária (20%). Observou-se que, embora todos os pacientes considerassem ter uma "boa" higiene bucal, o tratamento periodontal foi identificado como o de maior necessidade entre os pacientes (67,93%). A presença do cirurgião-dentista no corpo clínico hospitalar foi considerada por todos os entrevistados como fundamental para contribuir no cuidado integral à saúde dos pacientes hospitalizados. Quanto ao papel do dentista em um hospital, a grande maioria dos pacientes (90,63%) afirmou ser o "cuidar dos dentes". Assim, conclui-se que todos os pacientes têm conhecimento do quão é importante a manutenção das condições adequadas de saúde bucal, principalmente em pacientes hospitalizados.

Application of optical coherence tomography (OCT) to nondestructive inspection of dentures

The porosity of denture base resins continues to be one of the undesirable characteristics of acrylic resins. It is commonly accepted that porosity of the denture not only often leads to denture fractures, but also may function as a reservoir of potential pathogens. The purpose of this study was to present the first OCT images of finished dentures using a new advanced-type OCT scanner we have developed, and to discuss the application of our new OCT system for nondestructive inspection of dentures. Ten newly fabricated full dentures of outpatient of the National Center for Geriatrics and Gerontology in Japan were selected for this study. Two types of denture base resins were used for inspection by OCT, which provided clear images of all the dentures examined. Internal structures, not visually detectable, inspection, can be observed using this OCT system. It is concluded that OCT can detect nonvisible internal structures in dentures, a finding not reported to date. OCT may, therefore, be an appropriate method for detecting interior defects in dentures nondestructively.

[Oral infection control in hospitalized patients: an approach to cardiologist and intensive care units doctors]

This paper aims to find the current level of periodontal med-care knowledge, as well as the possible existence of some oral infection control protocol regarding hospitalized patients. Our sample gathered 110 cardiologists and intensive care units doctors selected from medical teams of five Rio de Janeiro hospitals. Preliminary numbers: 75.4% said to have heard something about Periodontal Medicine, although only 30% out of this group admitted to have read something concerning such subject. On the other side, only 2.7% of the sample informed to do consistent information searching along their patients anamnese, while 58.2% out of this group admitted such procedure conditional to the patient's general state at the due moment. Through such numbers, we tend to come up to the conclusion that, be it either through direct or indirect Periodontal Medicine technical information (and consequently with regards to the absolut importance of preservation and control of oral biofilm and its impact on one's systemic health), the matter has been dimly spread among medical groups. The search also revealed the probability that Rio de Janeiro hospitals lack either units or agents designed for prevention and control of oral infection; consequently, such organizations do not have any kind of protocols, reliable or not, concerned to oral infections.

Nosocomial pneumonia: importance of the oral environment

Nosocomial pneumonia, especially ventilator-associated pneumonia, is a common infection in ICUs. The main etiologic factors involve colonizing and opportunistic bacteria from the oral cavity. Oral hygiene measures, including the use of oral antiseptic agents, such as chlorhexidine, have proven useful in reducing its incidence. The objective of this article was to review the literature on the importance of the oral environment in the development of nosocomial pneumonia.

A retrospective study on the microbiology in patients with oral complaints and oral mucosal lesions

OBJECTIVE

The aim of this study was to microbiologically analyze oral mucosal samples collected during 2 years from patients with oral mucosal complaints.

MATERIALS AND METHODS

Mucosal scraping samples were taken from 297 patients and semiquantified by culture for detection of opportunistic microorganisms e.g. Staphylococcus aureus, enterococci, aerobic Gram-negative bacilli (AGNB) and yeasts. Antibiotic susceptibility test was performed.

RESULTS

Altogether 297 patients were sampled (mean age 56.8 +/- 20.7). Among the 110 patients with known medical condition, 48 were systemically immunocompromised, 35 had systemic diseases, and 27 had only local oral complaints. Opportunists in moderate growth or more were present commonly in all three groups and most frequent in the immunocompromised patients (66.7%). Candida species were the most frequent opportunist (68.8%), however, their level was low and combinations with bacterial opportunists were common (39.6%). All bacterial opportunists tested were antibiotic multiresistant. Follow-up samples were collected in 23 cases out of which seven showed still presence of opportunists in heavy growth despite repeated treatment with ciprofloxacin.

CONCLUSIONS

This study showed a frequent presence of bacterial and fungal opportunists in patients with oral mucosal complaints, which were most common in immunocompromised individuals, however, also frequent in patients with local oral complaints only. Systematic evaluation of different treatment strategies is needed.

Smoking prevalence among dentists in Hyogo, Japan 2003

We examined smoking prevalence among dentists in Hyogo, Japan, as smoking would influence their smoking cessation interventions to encourage their patients to stop smoking. In 2003, a self-administered questionnaire was mailed to all members of the Hyogo Dental Association (HDA) in Japan. Of the 1,133 members of the HDA, 327 were current smokers (28.9%). Smoking prevalence among HDA members was significantly higher than that among Japan Medical Association (JMA) members in 2004, as previously reported (16.2%) (p<0.01). Although smoking prevalence among HDA members decreased overall in 2003 in comparison with 2000, smoking prevalence among dentists aged 20-39 yr increased. These findings indicate that smoking was more prevalent among dentists in Hyogo Prefecture than among Japanese medical doctors. It is important to promote smoking cessation among Japanese dentists so that dentists will be more likely to encourage their patients to quit smoking.

Oral care interventions and oropharyngeal colonization in children receiving mechanical ventilation

BACKGROUND

Recent progress in identification of oral microorganisms has shown that the oropharynx can be a site of origin for dissemination of pathogenic organisms to distant body sites, such as the lungs.

OBJECTIVE

To compare the oropharyngeal microbiological profile, duration of mechanical ventilation, and length of stay in the intensive care unit of children receiving mechanical ventilation who had pharmacological or nonpharmacological oral care.

METHODS

A randomized and controlled study was performed in a pediatric intensive unit in São Paulo, Brazil. A total of 56 children were randomly assigned to an experimental group (n=27, 48%) that received oral care with use of 0.12% chlorhexidine digluconate or a control group (n=29, 52%) that received oral care without an antiseptic. Oropharyngeal secretions were collected and cultured on days 0, 2, and 4, and at discharge.

RESULTS

The 2 groups had similar demographic characteristics, preexisting underlying diseases, and pharmacological, nutritional, and ventilatory support. Gram-negative bacteria were the predominant pathogens: Acinetobacter baumannii, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Enter-obacter species. The 2 groups did not differ significantly in the colonization of normal (P= .72) or pathogenic (P= .62) flora, in the duration of mechanical ventilation (P= .67), or in length of stay in the intensive care (P= .22).

CONCLUSION

Use of chlorhexidine combined with nonpharmacological oral care did not decrease the colonization profile, duration of mechanical ventilation, or length of stay in critically ill children receiving mechanical ventilation.

Avaliação da existência de controle de infecção oral nos pacientes internados em hospitais do estado do Rio de Janeiro

O objetivo do presente estudo foi verificar a existência de um protocolo de controle de infecção oral nos hospitais do Estado do Rio de Janeiro. Foram avaliados 62 hospitais da rede pública e privada. Quando questionados se existia na instituição algum procedimento destinado aos pacientes internados (no caso de UTIs), 39% dos hospitais pesquisados responderam positivamente. Das instituições pesquisadas, apenas 15% possuem um protocolo regular para o controle de placa nos pacientes internados. Pesquisas têm demonstrado a inter-relação da doença periodontal com doenças sistêmicas, como doenças cardiovasculares, osteoporose, nascimento de bebês de baixo peso e parto prematuro, diabetes e doenças respiratórias. A cavidade oral tem sido considerada como um potente reservatório de patógenos respiratórios. Diante destes fatos, evidencia-se a importância da higiene bucal como um meio de se prevenir patologias diversas. Desta forma, existe a necessidade de se criar um protocolo de controle de infecção da cavidade oral para contribuir para a redução da mortalidade de pacientes internados e propor medidas preventivas para este fim.

Periodontal therapy

Periodontal disease is the most common disease in small animal patients. It not only creates severe localized infection, but it has been linked to numerous severe systemic maladies. Proper therapy of this disease process results in a significant increase in the overall health of the patient. The treatment of periodontal disease is currently evolving due to the acceptance of the specific plaque hypothesis of periodontal disease. These findings have led to the development of the "one-stage full-mouth disinfection" treatment as well as a vaccine against these organisms. However, the cornerstone of therapy is still meticulous plaque control. This control is achieved via a combination of regular dental prophylaxis and home care. With progressive disease, advanced periodontal surgery or extraction becomes necessary.

Pharmacologic prevention of aspiration pneumonia: a systematic review

BACKGROUND

Aspiration pneumonia is a common cause of morbidity and mortality. Several approaches, including bed positioning, dietary changes, and oral hygiene, have been proposed to prevent aspiration pneumonia, yet few data are available on the efficacy of pharmacologic interventions in reducing the rate of aspiration.

OBJECTIVE

This study was a systematic literature review of the pharmacologic prevention of aspiration pneumonia.

METHODS

We searched MEDLINE (1996-2006); EMBASE (1974-2006); Cumulative Index to Nursing & Allied Health Literature (CINAHL) (1982-2006); Health Services Technology, Administration, and Research (HealthSTAR) (1975-2006); and the Cochrane Library for relevant articles. References of all included articles were reviewed. Studies were included if they had a prospective, controlled design with a primary outcome of prevention of aspiration pneumonia. Surrogate outcomes that had a direct link to decreasing the incidence of aspiration pneumonia were considered. Selected articles were reviewed independently by 2 authors.

RESULTS

Of 1108 studies reviewed, 20 were analyzed. Angiotensin-converting enzyme inhibitors may be beneficial in selected patients at high risk for aspiration. Capsaicin may be a low-risk approach to stimulate swallowing and cough reflexes. Amantadine, cabergoline, and theophylline may cause serious adverse events, and their routine use for prevention of aspiration pneumonia is not recommended. Cilostazol should not be used because of the increased risk for bleeding.

CONCLUSIONS

Limited information is available on benefits and risks to guide an evidence-based approach to the pharmacologic prevention of aspiration pneumonia. Considering the high incidence of aspiration pneumonia in older adults, large randomized clinical trials on the effectiveness of pharmacologic interventions are warranted.

Oral hygiene of elderly people in long-term care institutions ? a cross-sectional study

OBJECTIVE

The aim of this cross-sectional study was to assess the level of oral hygiene in elderly people living in long-term care institutions and to investigate the relationship between institutional and individual characteristics, and the observed oral cleanliness.

MATERIALS AND METHODS

Clinical outcome variables, denture plaque and dental plaque were gathered from 359 older people (14%) living in 19 nursing homes. Additional data were collected by a questionnaire filled out by all health care workers employed in the nursing homes.

RESULTS

Only 128 (36%) residents had teeth present in one or both dental arches. About half of the residents (47%) wore complete dentures. The mean dental plaque score was 2.17 (maximum possible score = 3) and the mean denture plaque score was 2.13 (maximum possible score = 4). Significantly more plaque was observed on the mucosal surface of the denture with a mean plaque score of 2.33 vs. 1.93 on the buccal surface (p < 0.001). In the multiple analyses only the degree of dependency on an individual level was found to be significantly correlated with the outcome dental plaque (odds ratio: 3.09) and only the management of the institution with denture plaque (odds ratio: 0.43).

CONCLUSION

Oral hygiene was poor, both for dentures and remaining teeth in residents in long-term care institutions and only the degree of dependency of the residents and the management of the institutions was associated with the presence of dental plaque and denture plaque respectively.

Pneumonia in nonambulatory patients

BACKGROUND

Considerable evidence exists to support a relationship between poor oral health, the oral microflora and bacterial pneumonia, especially ventilator-associated pneumonia in institutionalized patients. Teeth or dentures have nonshedding surfaces on which oral biofilms (that is, dental plaque) form that are susceptible to colonization by respiratory pathogens. Subsequent aspiration of respiratory pathogens shed from oral biofilms into the lower airway increases the risk of developing a lung infection. In addition, patients may aspirate inflammatory products from inflamed periodontal tissues into the lower airway, contributing to lung insult.

TYPES OF STUDIES REVIEWED

The author reviewed laboratory studies, clinical trials and review articles.

CONCLUSIONS

A number of studies have shown that the mouth can be colonized by respiratory pathogens and serve as a reservoir for these organisms. Other studies have demonstrated that oral interventions aimed at controlling or reducing oral biofilms can reduce the risk of pneumonia in high-risk populations. Taken together, the evidence is substantial that improved oral hygiene may prevent pneumonia in vulnerable patients.

CLINICAL IMPLICATIONS

Institution of rigorous oral hygiene regimens for hospitalized patients and long-term-care residents may reduce the risk of developing pneumonia.

Alzheimer's disease

BACKGROUND

The authors review the clinical features, epidemiology, pathophysiology, medical management, dental findings and dental treatment of patients with Alzheimer's disease (AD).

STUDIES REVIEWED

The authors conducted MEDLINE searches for 2000 through 2005 using the terms "Alzheimer's disease," "geriatric," "epidemiology," "pathophysiology," "treatment" and "dentistry." Reports selected for further review included those published in English in peer-reviewed journals. The authors gave preference to articles reporting randomized, controlled trials.

RESULTS

AD is a progressive and fatal neurodegenerative disorder characterized by cognitive dysfunctions, particularly in learning and memory, and the emergence of behavioral abnormalities. Deficiencies in the cells responsible for storage and processing of information underlie the cognitive, functional and behavioral changes seen in patients with the disorder.

CLINICAL IMPLICATIONS

As the elderly population grows, increasing numbers of Americans with AD will require dental treatment. The prevalence of dental disease likely will be extensive, because of diminished salivary flow and patients' inability to perform appropriate oral hygiene techniques. Preventive dental education for the caregiver and use of saliva substitutes and anticaries agents by the patient are indicated.

Oral health and morbidity--implications of oral infections on the elderly

Detrimental effects of oral infections on general health have been known for almost 3000 years. Modern studies, however, have cast new light on the pathogenic mechanisms by which oral infections appear to link with morbidity and mortality. In particular, among the elderly, poor dental health seems to associate with all-cause mortality. This review aims to provide an overview of present knowledge of these issues, starting from dental bacteraemia, oral mucosal infections and problems of drug resistance and, briefly, discussing what is known about the link between oral health and some systemic diseases such as atherosclerosis and type-2 diabetes. The main conclusions are that scientific evidence is still weak on these interactions and that the elderly should be better taken into account when planning future studies. Functions of the body differ in the frail and diseased from those of the young. Consequently, novel prevention and treatment strategies should be developed and properly tested for combating oral infections in elderly populations. Specific suggestions for further research are outlined.

Discrimination of functional capacity for oral hygiene in elderly Spanish people by the Barthel General Index

OBJECTIVES

To explore, among the institutionalized elderly in Spain, the association between functional dependence in manipulating aids used in oral self-care (oral hygiene dependence) and general functional capacities, as measured by the Index of Activities of Daily Oral Hygiene (ADOH) and the Barthel Index (BI), respectively.

METHODS

A cross-sectional study was performed in 2002 on 390 Spanish residents of a residential home for the elderly aged, 65-101 years. All study subjects underwent a oral examination and their ADOH and BI scores assessed. The association between the index scores was studied and the discriminant capacity of BI for oral hygiene dependence was calculated.

RESULTS

The mean number of decayed, missing, or filled permanent teeth (+/-SD) was 26.6 +/- 7.3. The mean BI score was 68.31 (95% CI 64.35-72.27), and 172 individuals (44.1%; 95% CI 39.2-49.0%) were independent in all BI-measured functions. The mean ADOH score was 2.43 (95% CI 2.11-2.75), and 238 individuals (61.0%; 95% CI 56.2-65.9%) were independent for oral hygiene, 39 (10.0%; 95% CI 7.2-13.4%) required assistance (assistive devices), and 113 (29.0%; 95% CI 24.5-33.5%) were completely dependent. The BI scores were significantly correlated with the ADOH scores (r = -0.80, P < 0.001). The BI showed a high discriminant capacity to identify the individuals who were dependent for oral hygiene in this population (area under the ROC curve +/- SE = 0.929 +/- 0.013). Using the optimal cut-off point according to the Youden Index (<61), the sensitivity was 0.87 +/- 0.03 and specificity 0.87 +/- 0.02.

CONCLUSION

There is a close association between BI and ADOH in this population, which could be useful to identify elderly individuals who are dependent for oral hygiene.

Effect of various antibacterial preparations on the pathogenic oral flora in elderly patients fed via nasogastric tube

Oropharyngeal colonization by pathogenic gram-negative bacilli (GNB) and Staphylococcus aureus is associated with aspiration pneumonia. Decolonization in high-risk populations may be important. We prospectively evaluated six antiseptic compounds in nasogastric tube-fed frail elderly patients; only polymixine reduced oropharyngeal colonization with GNB. None had an effect on S. aureus colonization.

Respiratory pathogens in dental plaque of hospitalized patients with chronic lung diseases

Bacterial cultivation studies have shown that dental plaque is a reservoir for respiratory pathogens in intensive care unit patients and in elderly who are debilitated, hospitalized or in a nursing home, placing them at risk of bacterial pneumonia. No information is available, however, concerning dental plaque as a reservoir of putative respiratory pathogens in hospitalized patients with chronic lung diseases. Supragingival plaque colonization of 34 hospitalized chronic lung-diseased Romanian citizens, excluding those with tuberculosis and less than 20 teeth, was therefore assessed by checkerboard DNA-DNA hybridization using a selected panel of whole genomic DNA probes produced from eight respiratory pathogens and eight oral pathogens. Thirty-one lung-healthy dental outpatients served as reference population. Respiratory pathogens were detected in plaque from 29 of the 34 (85.3%) hospitalized patients and 12 of the 31 (38.7%) reference population subjects. Staphylococcus aureus, Pseudomonas aeruginosa, Acinetobacter baumannii, and Enterobacter cloacae occurred significantly (p<0.05) more frequent among the hospitalized patients. Hospitalized chronic lung-diseased patients harbored in their supragingival plaque samples bacteria known to cause nosocomial pneumonia significantly (p<0.001) more frequent than lung-healthy dental outpatients. Our results indicate that dental plaque in patients with chronic lung diseases often serves as a reservoir of bacteria known to cause nosocomial pneumonia in susceptible individuals.

Pneumonia in the Long-Term Care Setting: Etiology, Management, and Prevention

1.Nursing-home acquired pneumonia (NHAP) is a major cause of death and disability among elderly nursing home residents, despite the availability of new antimicrobials and diagnostic techniques. 2. Elderly individuals with NHAP have vague clinical presentations and unique institutional limitations can lead to delays in diagnosis, treatment, and poor resident outcomes. 3. Successful management of the resident with pneumonia includes choice of antibiotic therapy, excellent nursing care, and thoughtful consideration of treatment setting. 4. Preventive strategies to reduce the risk of NHAP include attention to vaccination status and oral hygiene care to reduce bacterial colonization of potential respiratory pathogens.

Oral hygiene care for adults with dementia in residential aged care facilities

OBJECTIVE

The objective of this systematic review was to report on the best available evidence relating to oral hygiene for adults with dementia in residential aged care facilities, including: INCLUSION CRITERIA: This review considered any randomised or non-randomised controlled studies, cohort studies, case-control studies, multiple time series studies, uncontrolled studies, descriptive studies and opinions of respected authorities (including theses and other publications) related to residents with dementia living in residential aged care facilities in Australia and overseas; community-dwelling adults with dementia; and special needs adult populations (for preventive oral hygiene care strategies and interventions).The review considered studies and publications designed to:1 quantify the oral health status of older adults living in residential aged care facilities;2 quantify the oral health status of adults with dementia living in the community and in residential aged care facilities;3 evaluate tools used to assess the oral health of residents by staff and carers working in residential aged care facilities;4 evaluate preventive oral hygiene care strategies and interventions used in special needs adult populations (including adults with dementia); and5 evaluate oral health care training and oral hygiene care provision, staff and carers working in residential aged care facilities.Dental outcome measures of interest were those relating to the prevalence, incidence, experiences and increments of oral diseases and conditions including: denture problems, coronal and root caries, periodontal diseases (plaque accumulation, gingivitis, loss-of-attachment), oral mucosal conditions, xerostomia and salivary gland hypofunction, tooth loss, difficulty chewing, behavioural problems and pain/discomfort. Related characteristics and outcomes of interest included: medical conditions, medications, cognitive status, functional status, nutritional status and sociodemographics.

SEARCH STRATEGY

The aim of the search was to locate relevant English-language studies and publications appearing between 1980 and 2002. The search utilised a two-step approach, involving an initial search of electronic databases using combinations of key words followed by a second extensive search carried out using the identified key words. This was supplemented with a secondary search of the references cited in the identified studies. Electronic database searched were: Cinahl, Embase, Psycinfo, Medline and Current Contents.

METHODOLOGICAL QUALITY

All selected studies were critically appraised by two reviewers prior to inclusion in the review.

RESULTS

In regards to relevance, incidence, experiences, and increments of oral diseases and conditions, possible risk factors identified included: saliva dysfunction, polypharmacy, comorbid medical conditions, swallowing and dietary problems, increased functional dependence, need for assistance with oral hygiene care, and poor access and utilisation of dental care.Evidence on the use of assessment tools by carers to evaluate residents' oral health showed that successful assessment of residents with and without dementia by nursing staff requires appropriate staff training by a dental professional. Coupled with appropriate training, an oral assessment screening tool designed for residents with dementia has been successfully used by nursing and care staff to identify residents requiring further review by dental professionals. Expert opinion in the field indicates that oral assessment screenings by a staff member and then by a dentist would ideally be undertaken upon admission to a facility, and regularly thereafter by staff and/or dentists as required.Clinicians and researchers suggested that oral hygiene care strategies to prevent oral diseases and conditions were found to be effective in preventing oral diseases, and thus are relevant for use in the resident with dementia.In regards to the provision of dental treatment and ongoing management of oral diseases and conditions, the use of adjunctive and preventive aids were found to be effective when introduced in conjunction with a staff training program:Expert opinion suggests that behaviour management techniques will increase the potential of performing oral hygiene care interventions.

CONCLUSIONS

This review suggests that the training of staff in the form of a comprehensive practically oriented program addressing areas such as oral diseases, oral screening assessment, and hands-on demonstration of oral hygiene techniques and products is likely to have a positive impact on the management of oral hygiene care within residential aged care facilities. The review also identified that regular brushing with fluoride toothpaste, use of therapeutic fluoride products and application of therapeutic chlorhexidine gluconate products are validated by research as effective for the general population and some populations with special needs.

Blood Test Values and Community Periodontal Index Scores in Medical Checkup Recipients

BACKGROUND

We examined the blood test values of people who received general medical checkups and their Community Periodontal Index (CPI) score.

METHODS

A total of 7,452 persons (5,742 males and 1,710 females), who had general medical and dental checkups, were the subjects of the study. Many were people who worked for companies in and around Nagoya and their family members, ranging in age from 16 to 80 years. The blood test in our study consisted of 37 items used in general blood tests. Partial-mouth recordings were used to measure CPI scores. The highest CPI score for each subject was used for analysis. Odds ratios and confidence interval values were obtained using the Mantel-Haenszel method to analyze the results.

RESULTS

CPI scores of 3 and 4 were related to the test values of high-density-lipoprotein cholesterol, serum iron, white blood cell count, fasting blood sugar, glycosylated hemoglobin A1, glycosylated hemoglobin A1c, and C-reactive protein.

CONCLUSION

Blood test values tended to show correlations with CPI scores, more clearly seen in males than in females.

High correlation between the bacterial species in denture plaque and pharyngeal microflora

OBJECTIVES

The morbidity and mortality of the dependent elderly that result from aspiration pneumonia are recognized as a major geriatric health problem. Most cases of bacterial pneumonia are initiated following colonization or superinfection of the pharynx by pathogenic bacteria, followed by aspiration of pharyngeal contents. A recent study revealed that bacteria, that commonly cause respiratory infection, colonized the dentures of dependent elderly. This suggests that denture plaque may function as a reservoir of potential respiratory pathogens to facilitate colonization on the pharynx. The purpose of this study was to determine the possible correlation between denture and pharyngeal microflora.

STUDY DESIGN

The denture and pharyngeal bacterial flora of 50 dependent elderly were examined, and the microorganisms identified by culturing. The agreement between the bacterial species in denture plaque and pharyngeal microflora was investigated using the Kappa method.

RESULTS

The microorganism species on the dentures and pharyngeal mucosa of the subjects had an agreement rate of 68.5%. The agreement rate for each of the bacterial species of the dentures and pharynx was also demonstrated to be high.

CONCLUSIONS

Dentures should be considered an important reservoir of organisations which could colonise the pharynx, and the importance of controlling denture plaque for the prevention of aspiration pneumonia cannot be overemphasized.

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.

Pseudomonas aeruginosa and the oropharyngeal ecosystem of tube-fed patients

We evaluated whether elderly patients fed with nasogastric tubes (NGT) are predisposed to Pseudomonas aeruginosa colonization in the oropharynx. Fifty-three patients on NGT feeding and 50 orally fed controls with similar clinical characteristics were studied. The tongue dorsum was swabbed and cultured. P. aeruginosa was isolated in 18 (34%) of the NGT-fed group but in no controls (p<0.001). Other gram-negative bacteria were cultured from 34 (64%) of NGT-fed patients as compared with 4 (8%) of controls (p<0.001). Antibiotic susceptibility of the oropharyngeal P. aeruginosa isolates was compared with that of isolates from sputum cultures obtained from our hospital's bacteriologic laboratory. The oropharyngeal isolates showed a higher rate of resistance; differences were significant for amikacin (p<0.03). Scanning electron microscope studies showed a biofilm containing P. aeruginosa organisms. The pulsed-field gel electrophoresis profile of these organisms was similar to that of P. aeruginosa isolates from the oropharynx. NGT-fed patients may serve as vectors of resistant P. aeruginosa strains.

Interventions to prevent aspiration pneumonia in older adults: a systematic review

A systematic review was conducted to assess the effectiveness of the following interventions for prevention of aspiration pneumonia (AP) in older adults: compensatory strategy/positioning changes, dietary interventions, pharmacologic therapies, oral hygiene, and tube feeding. Data sources included a key word search of the MEDLINE, EMBASE, Cochrane Library, CINAHL, and HealthSTAR databases and hand searches of six journals. Reference lists of relevant primary and review articles were searched. Studies included were randomized, controlled trials (RCTs) enrolling adults aged 65 and older at risk of and assessed for AP. Two investigators extracted data on population, intervention, outcomes, and methodological quality. Of the 17 identified RCTs, eight met the selection criteria, two addressed dietary management or compensatory swallowing, two assessed pharmacological therapies, one assessed oral hygiene, and three assessed tube feeding. None of the eight trials reported use of blinding, and allocation concealment was unclear in five. Use of amantadine prevented pneumonia in one trial of nursing home residents. The antithrombotic agent cilostazol prevented AP in another trial but resulted in excessive bleeding. Insufficient data exist to determine the effectiveness of positioning strategies, modified diets, oral hygiene, feeding tube placement, or delivery of food in preventing AP. Considering how common the problem of AP is in older adults, larger, high-quality RCTs on the effectiveness of preventive interventions are warranted.

Assessments of oral health care in dependent older persons in nursing facilities

The number of dependent elderly with natural teeth is increasing dramatically. If these elderly persons do not receive proper oral health care, severe oral problems are likely to result. In conjunction with an oral health care education program for the staff of nursing facilities, oral health status was assessed and semi-structured interviews performed with residents and their relatives about oral health care. The assessments were made at baseline and at an 18-month follow-up. The project was conducted as a longitudinal, controlled study with an intervention and a control group. The aim of the study was to evaluate differences between the intervention and control group after oral health care intervention. At follow-up, it was shown that the intervention group had established more dental contacts. However, the results also indicated that the residents were not concerned about their oral health. Nursing staff therefore have to be responsible for oral health care if improved care for residents is to be realized.

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.

Effect of professional oral health care on the elderly living in nursing homes

OBJECTIVE

We evaluated the effectiveness of professional oral health care (POHC) given by dental hygienists once a week for 24 months to 141 elderly persons needing daily care and living in 2 nursing homes.

STUDY DESIGN

Elderly subjects with POHC and without POHC living in 2 nursing homes were examined for 24 months to detect any fevers of 37.8 degrees C or more and the prevalence of fatal aspiration pneumonia. The numbers of Staphylococcus species and Candida albicans in swab samples from oral cavities were compared between the POHC group and the non-POHC group. The amounts of methylmercaptan exhaled in the POHC group were determined and compared with those in the non-POHC group.

RESULTS

The prevalence of fevers of 37.8 degrees C or more in the subjects receiving POHC was significantly lower than in the non-POHC group (P < .05). We found that the ratio of fatal aspiration pneumonia in the POHC group during the 24 months was significantly lower than in the non-POHC group (P < .05). Numbers of C albicans species in samples obtained from the oral cavity after 6 months of POHC were significantly lower than those in the non-POHC group (P < .01). POHC resulted in the reduction of the presence of Staphylococcus but not to a statistically significant extent. The amounts of methylmercaptan exhaled by the POHC group were significantly less than those of the non-POHC group (P <.05).

CONCLUSION

This study showed that POHC administered by dental hygienists to a group of elderly patients needing daily nursing care was associated with a reduction in prevalence of fever and fatal pneumonia.

Development of a systematic oral care program for frail elderly persons

The purpose of this study was to develop, implement and evaluate a systematic oral care program for community-dwelling-dependent or institutionalized elderly adults. The study group consisted of 20 dependent elderly adults of which 15 were living in the community and five were in a nursing home. After eight weeks of systematic oral care, the plaque and gingival indices were scored and compared with baseline measurements. Also at the end of the study, caregivers completed a questionnaire that assessed their perspective on the advantages, disadvantages, burden and fatigue in providing the systematic oral care program. The results of this study demonstrate that a systematic oral care program reduced plaque and gingival indices for the subjects as well as reducing the caregivers' burden and fatigue in providing daily oral care.