Oral Hygiene can Reduce the Incidence of and Death Resulting from Pneumonia and Respiratory Tract Infection

Abstract

Clinical question.Does better oral hygiene prevent health care–associated pneumonia or lower the rate of respiratory infections among elderly people in nursing homes and hospitals?Review methods.The authors searched two databases for articles published from 1996 to 2007. The inclusion criteria were clinical studies linking oral hygiene to health care–associated pneumonia or respiratory tract infection in elderly people.Main results.The authors evaluated a total of 328 studies: 191 from literature searches and 137 from hand-searched reference lists. Of the 15 studies that met the inclusion criteria, one was a systematic review, five were reports of four randomized controlled trials (RCTs) and nine had non-RCT designs. For each RCT, the authors calculated the absolute risk reduction (ARR) in the event rate and the number needed to treat (NNT) with the studied intervention to prevent one outcome of interest. The interventions in the RCTs varied and included use of chlorhexidine rinse, weekly professional oral care and toothbrushing after every meal (with 1 percent povidoneiodine scrubbing of the pharynx, when necessary). The ARRs ranged between 7 and 12 percent, two of which were statistically significant. The highest (that is, least effective) NNT was 14 people. The main conclusions from the non-RCT clinical studies were similar to those from the RCTs. The results of both types of studies indicated a correlation between poorer oral hygiene or deficient denture hygiene and pneumonia or respiratory tract infection among elderly people in nursing homes or hospitals.Conclusions.There is good evidence that mechanical oral hygiene practices reduce the progression or occurrence of respiratory diseases in high-risk elderly people in nursing homes or hospitals. Mechanical oral hygiene practices may prevent the death of about one in 10 elderly residents of nursing homes from health care–associated pneumonia.COMMENTARYImportance and context.In 1999, 2.8 percent of nursing home residents were diagnosed as having pneumonia.1Vital and Health Statistics Series 13, No, 152. The National Nursing Home Survey: 1999 Summary. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, Md.June 2002“www.cdc.gov/nchs/data/series/sr_13/sr13_152.pdf”Google Scholar In addition, nosocomial (institutionally acquired) pneumonia has been associated with high fatality rates.2Guidelines for prevention of nosocomial pneumonia.MMWR Morbid Mortal Weekly Rep. 1997; 46 (Accessed Aug. 2, 2010.): 1-79“www.cdc.gov/mmwr/preview/mmwrhtml/00045365.htm”PubMed Google Scholar Dentists often treat people who live in long-term–care settings such as nursing homes. They need to be able to provide information to these residents, their families and the facilities in which they reside about the importance of maintaining adequate daily oral hygiene.Strengths and weaknesses of the systematic review.The authors used an appropriate search strategy and methodology, which included reports of five RCTs and several studies of weaker designs. They focused their analysis on clinically relevant outcomes of the included RCTs. Their findings were supported by the results of the non-RCTs, which strengthened the overall conclusions. The authors stated that an analysis of other risk factors for these outcomes (for example, smoking or other diseases) was beyond the scope of their review.Strengths and weaknesses of the evidence.The authors assessed one systematic review (that is, type 1 evidence); five RCT publications (type 2 evidence), two of which involved the same trial; and nine non-RCT studies (type 3 evidence). The five RCTs were consistent in that all showed positive preventive effects of oral hygiene interventions on pneumonia and respiratory tract infection. Results of the studies were heterogeneous and could not be subjected to a meta-analysis owing to differences in primary end points, methodological quality and study design. A quality assessment of the RCTs showed that investigators in one study used an appropriate double-masking methodology, and investigators in three studies used an adequate random-allocation method. All of these RCTs demonstrated positive preventive effects of oral care on pneumonia or respiratory tract infection in nursing home residents. The non-RCT studies had heterogeneous designs, but their main conclusions were similar to those of the RCTs.Implications for dental practice.It is highly significant that about one in 10 deaths resulting from pneumonia among elderly residents of nursing homes may be prevented by improving oral hygiene practices. These results reinforce the importance of communicating with residents, families and facilities about the critical nature of maximizing oral health care. Clinical question.Does better oral hygiene prevent health care–associated pneumonia or lower the rate of respiratory infections among elderly people in nursing homes and hospitals? Does better oral hygiene prevent health care–associated pneumonia or lower the rate of respiratory infections among elderly people in nursing homes and hospitals? Review methods.The authors searched two databases for articles published from 1996 to 2007. The inclusion criteria were clinical studies linking oral hygiene to health care–associated pneumonia or respiratory tract infection in elderly people. The authors searched two databases for articles published from 1996 to 2007. The inclusion criteria were clinical studies linking oral hygiene to health care–associated pneumonia or respiratory tract infection in elderly people. Main results.The authors evaluated a total of 328 studies: 191 from literature searches and 137 from hand-searched reference lists. Of the 15 studies that met the inclusion criteria, one was a systematic review, five were reports of four randomized controlled trials (RCTs) and nine had non-RCT designs. For each RCT, the authors calculated the absolute risk reduction (ARR) in the event rate and the number needed to treat (NNT) with the studied intervention to prevent one outcome of interest. The interventions in the RCTs varied and included use of chlorhexidine rinse, weekly professional oral care and toothbrushing after every meal (with 1 percent povidoneiodine scrubbing of the pharynx, when necessary). The ARRs ranged between 7 and 12 percent, two of which were statistically significant. The highest (that is, least effective) NNT was 14 people. The main conclusions from the non-RCT clinical studies were similar to those from the RCTs. The results of both types of studies indicated a correlation between poorer oral hygiene or deficient denture hygiene and pneumonia or respiratory tract infection among elderly people in nursing homes or hospitals. The authors evaluated a total of 328 studies: 191 from literature searches and 137 from hand-searched reference lists. Of the 15 studies that met the inclusion criteria, one was a systematic review, five were reports of four randomized controlled trials (RCTs) and nine had non-RCT designs. For each RCT, the authors calculated the absolute risk reduction (ARR) in the event rate and the number needed to treat (NNT) with the studied intervention to prevent one outcome of interest. The interventions in the RCTs varied and included use of chlorhexidine rinse, weekly professional oral care and toothbrushing after every meal (with 1 percent povidoneiodine scrubbing of the pharynx, when necessary). The ARRs ranged between 7 and 12 percent, two of which were statistically significant. The highest (that is, least effective) NNT was 14 people. The main conclusions from the non-RCT clinical studies were similar to those from the RCTs. The results of both types of studies indicated a correlation between poorer oral hygiene or deficient denture hygiene and pneumonia or respiratory tract infection among elderly people in nursing homes or hospitals. Conclusions.There is good evidence that mechanical oral hygiene practices reduce the progression or occurrence of respiratory diseases in high-risk elderly people in nursing homes or hospitals. Mechanical oral hygiene practices may prevent the death of about one in 10 elderly residents of nursing homes from health care–associated pneumonia. There is good evidence that mechanical oral hygiene practices reduce the progression or occurrence of respiratory diseases in high-risk elderly people in nursing homes or hospitals. Mechanical oral hygiene practices may prevent the death of about one in 10 elderly residents of nursing homes from health care–associated pneumonia.