Oral Health Disparities in Older Adults: Oral Bacteria, Inflammation, and Aspiration Pneumonia

Key points

Epidemiology

Pneumonia is a common disease. Together with influenza, pneumonia was the eighth most common cause of death in the United States in 2011.⁴ Classification of pneumonia is based on the residence of the victim at the time of the initiation of the infection. Thus, community-acquired pneumonias are those where the infection is contracted within the community. A recent report found the crude and age-adjusted incidences of pneumonia were 6.71 and 9.43 cases per 1000 person-years (10-year risk was

Risk factors

Dysphagia (swallowing dysfunction) is among the most important risk factors for AP. Dysphagia is a relatively common finding in elderly, especially those in nursing homes,¹⁴ where it can be a result of Parkinson disease, Alzheimer disease, stroke, other neurodegenerative conditions, or advanced aging.¹⁵ A recent systematic review that sought to identify risk factors for AP found dysphagia to have a robust positive correlation with AP (odds ratio [OR], 9.84; 95% CI, 4.15–23.33).¹⁶ In a

Pathogenesis

Under normal circumstances, the lower airway presents formidable defense against bacteria that are aspirated.²⁰ A viscous mucous layer coating the epithelium, containing host-derived mucins and antimicrobial components such as lactoperoxidase, lysozyme, and other antimicrobial peptides,²¹ traps bacteria, which are then removed from the lung by the mucocutaneous escalator, a function of the unidirectional beating of epithelial cilia. Complex bacterial surface components interact with pattern

Oral health and AP

Before the mid 1990s, the role of oral conditions in the pathogenesis of AP, particularly poor oral hygiene and periodontal inflammation, was mostly ignored in the medical and nursing care setting, although it was understood that the source of the infectious agents causing the disease was often the oral microflora. This situation began to change as knowledge of the specific role of the oral microflora in the pathogenesis of pneumonia became available.1, 23 Much of the work at this time was

Oral care to prevent AP

Most of the available literature addressing the role of oral care in the prevention of pneumonia has been conducted in hospitalized and mechanically ventilated patients. However, several studies have also been conducted in nursing home patients. These studies have been critically reviewed in several recent, systematic reviews of the literature. Taken together, the evidence supports the link between poor oral health and pneumonia.37, 42, 43, 44 Oral interventions to reduce pulmonary infections

Tentative guidelines for oral care of dependent, elderly patients to prevent respiratory infection

An important development over the past 10 years has been the establishment of “ventilator bundles,” sets of evidence based-therapies instituted within health care settings to reduce the rate of VAP.⁶¹ These bundles include a number of recommended actions, including placement of the patient in a semirecumbent position, stress ulcer prophylaxis to decrease gastrointestinal bleeding, anticoagulant prophylaxis to decrease deep venous thrombosis, adjustment of sedation until the patient can follow

Summary

Understanding the risk factors and preventive measures for AP is essential in the care of hospitalized and institutionalized, disabled elderly. Control of oral biofilm formation in these populations reduces the numbers of potential respiratory pathogens in the oral secretions, which in turn reduces the risk for pneumonia. Together with other preventive measures (head of the bed position, promotion of salivary flow, vaccination against pathogens such as S pneumoniae, management of swallowing