Oral Care in Nursing Homes Reduces Pneumonia
July 15, 2002 3 minutes read
Abstract & Commentary
Synopsis: With oral brushing after every meal and weekly dental care, elderly nursing home residents had half as many febrile days and one third as many pneumonias, a difference that persisted whether they needed help with feeding.
Source: Yoneyama T, et al. J Am Geriatr Soc. 2002;50: 430-433.
Eleven nursing homes in Japan were used for this 2-year study, enrolling 417 residents with a mean age of 82 years. Only residents who were without acute disorders for the preceding 3 months were selected, and no subjects had any pre-existing pulmonary disease or required feeding tubes. No dentist had been in charge of the homes before the study began, and the majority had neglected oral care with plaque, periodontal disease, and caries.
Every study participant received a physical exam and baseline chest x-Ray, and then were randomized to a program of oral care or control group. The oral care group received 5 minutes of oral brushing of the gums, palate and tongue (without dentures present) after every meal, and some needed further scrubbing with povidone iodine 1%. They also received plaque and calculus control weekly from dentists or dental hygienists as needed. The control group performed some toothbrushing irregularly themselves but none from caregivers. Dentures were used by 45% of the total group, and these were all brushed daily and cleaned weekly.
New pneumonias were diagnosed in 11% of the patients receiving the oral care program and 19% of the control group, a statistically significant difference. The oral care group also had less febrile days (15%) vs. the control group (29%). More pneumonias were seen in the subset of patients who needed feeding assistance, but the ones who received oral care were less likely to develop pneumonia than the control group. Death rates from the pneumonias that developed were also less in the oral care group (7%) than the control group (16%), giving a relative risk of death from pneumonia for those who did not receive oral care of 2.4.
The effect of oral care on mental status and activity was measured every 6 months by Mini Mental Status Examinations (MMSE) and Activities of Daily Living (ADL) scales. Although both showed a tendency to improve from baseline in the oral care group, only the MMSE had a significant difference at the end of the 2- year study.
Comment by Mary Elina Ferris, MD
This article provides a strong case for more attention to oral care for the elderly. Besides the obvious benefits of a cleaner-feeling mouth, less periodontal disease, possibly better chewing ability and social interaction, there is now an association of less pulmonary infections with conscientious mouth care. An accompanying editorial in this journal calls it "cost-effective to maintain but costly to ignore."1 Since pneumonia is the leading cause of death and hospitalizations in nursing homes, even a 10% decrease would save more than $800 million in the United States annually. This could easily justify a full-time aide solely for oral care at each of our nation’s 19,000 nursing homes (at an estimated cost of < $500 million/year).
While the study might be criticized as starting with a neglected group of elderly at baseline, actually other studies have confirmed the poor state of oral care in institutions.2 Regulations and enforcement have not emphasized oral care in the past, and minimal training is provided to the nursing aides who generally implement the care. This study provided weekly dental professional care, which may not be feasible in many settings, so it remains to be demonstrated what effect a more modest improvement in oral care would produce.
The connection between oral pathogens and pneumonia, acquired through routine aspiration, has been suggested in epidemiological studies,3 and anerobic bacteria from the mouth have been demonstrated in transtracheal aspirates.4 Although this study does not prove that oral flora are the source of pulmonary infections, it lends support to greater emphasis on this often neglected aspect of nursing home care.
Dr. Ferris, Clinical Associate Professor, University of Southern California, is Associate Editor of Internal Medicine Alert.
References
1. Terpenning M, et al. J Am Geriatr Soc. 2002;50: 584-585.
2. Mojon P, et al. Gerodontology. 1997;14:9-16.
3. Terpenning M, et al. J Am Geriatr Soc. 2001;49: 557-563.
4. Finegold SM. Rev Infect Dis. 1991;13:S737-S742.
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