Impact Of Oral Hygiene On Risk Of Aspiration Pneumonia In Elderly Patients

Literature Review

Discuss about the Poor Oral Health Leads To Aspiration Pneumonia In Elderly Patients.

The oral cavity of humans is a complex microenvironment where variety of microorganisms competes for space and nutrition. However, the oral environment changes for toothless people compared to those who have teeth. Elderly people mostly use dentures and poor oral hygiene practices changes the mouth flora that is common in dentate person (Jaiswal et al., 2014). Hence, poor oral health leads to devastating health consequences and risk of local and systemic illness. In case of older adults, aspiration pneumonia is the most common consequence of aspiration pneumonia. Aspiration pneumonia is a disease characterized by misdirection of oropharyngeal contents due to dysphagia and initiation of infectious response in the lungs due to massive secretion of oral bacterial flora. Poor lung defense mechanism, swallowing and feeding problem and neurological problems are medical risk factor of aspiration pneumonia. In addition, dental decay and poor oral hygiene are dental risk factors the disease (Manabe et al., 2015). Since, elderly patients with long term care often have unmet oral hygiene and oral care needs, reviewing current evidence related to the topic is necessary to improve skills of care giver in daily oral care and assessment of oral hygiene status of elderly patient (Müller, 2015).

The main purpose of this assignment is to conduct a literature review on impact of oral hygiene on risk of aspiration pneumonia in elderly patients and assess oral hygiene practices implemented by elderly patient or their carer. . Another goal of literature review is to find out solutions to prevent aspiration pneumonia and death in elderly patient.

To get relevant research articles related to the topic, updated and peer-review research articles were retrieved from health care related databases like PubMed, CINAHL and Medline. The key terms used to retrieve research articles included ‘aspiration pneumonia in elderly patient’, ‘poor oral hygiene and aspiration pneumonia’ and ‘oral hygiene in elderly and risk of aspiration of pneumonia. The criteria for selecting article were as follows:

• All articles must be published within 2012 to 2018
• All articles must have elderly people as the study population
• All studies must discuss about the impact of oral health on aspiration pneumonia only and no other diseases
• The research must be published in English language
• The research done in other population group except elderly people will not be taken for literature review.

Based on the above inclusion and exclusion criteria, relevant articles related to the topic were taken. In addition, final list of articles were taken by reviewing the abstract and title of the articles and then screening the whole to find relevance to the research topic and study question.

Poor oral hygiene is recognized as a critical factor that increases risk of aspiration pneumonia in elderly people. Apart from oral care implemented by nurse in hospital setting, evidence has suggested that many patients deny removing dentures at night thus increasing the risk of pneumonia in elderly patient (Coker et al. 2017). This was confirmed by a study by Iinuma et al. (2015) which used prospective study design to investigate about oral health behavior and incidence of pneumonia in community living very elderly people. The oral health status and oral hygiene behavior of randomly selected elderly people was assessed. It was a three year follow-up study and oral health assessment questionnaire included questions on denture hygiene practices such as frequency of denture wearing, denture wearing during sleeps and use of denture cleaners. The main outcome of interest for the study was serious pneumonia event. The results of the study showed 48 events of pneumonia detected in participants. The study also established link between pneumonia and denture wearing habits during sleep in participants who developed pneumonia. Through statistical analysis of denture wearing habit during sleep, the study showed that such habit increase risk of pneumonia by 2-3 fold (Iinuma et al., 2015). This is a high quality and reliable research evidence as it used different statistical approach to provide robust evidence on impact of denture wearing habits on increased risk of aspiration pneumonia. This is also supported by Emami et al. (2015) who explained that nocturnal wear of complete dentures has adverse impact on sleep and oral health related quality of life. Taking cue from such evidence, carers of elderly patients can intervene to make patients aware about the risk of denture wearing and oral health programs can be implemented to teach denture caring habits to elderly population.

Effect of Poor Oral Hygiene on Aspiration Pneumonia

As the main purpose of the literature review is to assess oral hygiene practices and its impact on risk of aspiration pneumonia, the research by Coker et al. (2017) is considered relevant to the study purpose as it focuses on observing oral hygiene care interventions provided to hospitalized older people. Research in this area was important because older hospitalized patient have high chance of plaque build-up due to poor oral hygiene and it creates the condition for growth of opportunistic respiratory pathogens that contribute to aspiration pneumonia (Li et al., 2016). Removing dental plaque is vital to oral health, however oral hygiene care practices for nurses differ. Hence, by means of direct observation of care provided by nurse in 5 inpatient units, the study showed that oral hygiene care was implemented only in 36% of patient-nurse encounter and the main care interventions given to patient included supporting brushing of natural teeths, care of dentures, cleansing the tongue and moisturizing lips and oral tissues. Hence, the study showed inconsistency in oral care practices in the area of frequency of care and timing of oral hygiene. The number of encounters of nurse with patient for oral care was low (Coker et al., 2017). One major limitation that affected the credibility of the study was that it uses convenience sampling method and as participants were aware about the purpose of research, it is likely that their behavior might have changes. Despite this limitation, poor skill of carers in providing appropriate oral care was eminent. The study gave the direction to implement better practice guideline in clinical setting so that nurse can strict to desired frequency of oral hygiene and prevent infection in hospitalized older patient.

From the above evidence, it is understood that implementing proper oral care plays a crucial role in reducing risk of aspiration in elderly people. The review of studies also gave idea about several oral care interventions that can reduce incidence of pneumonia in patients with dentures. The study by Higashiguchi et al. (2017) is significant as it investigated about the efficacy of a new oral care intervention, wiping plus oral nutritional supplement on reducing mortality risk in elderly patient. Improving nutrition, addressing swallowing problem and providing oral care are important measures to prevent aspiration pneumonia. The research hypothesis was that the new intervention can improve swallowing function and reduce risk of pneumonia in elderly patients with poor nutritional status. The study was done with patients above the age of 75 years and participants were randomly assigned to intervention and control group. Intervention group received the new oral care intervention and the control group received conventional oral care. The cumulative incidence of pneumonia was found to be significantly higher in intervention group compared to control group. The study proved that combining oral wiping with oral nutritional supplement can act as an effective prophylactic intervention against aspiration pneumonia. Ohara et al. (2016) also supported the efficacy of wiping plus oral nutritional supplements in elderly people.  Hence, such novel interventions should be implemented to reduce the mortality rate of elderly patient due to aspiration pneumonia.

Conclusion:

From the review of research literature, the impact of poor oral hygiene practices on risk of aspiration pneumonia is established. The evidence clearly points out to the lack of awareness about oral hygiene practices among elderly patients and their carers. The research points to the need for implementation of effective oral health and hygiene programs in community so that nurses or carers can gain proper knowledge related to guidelines for oral health practices and preventing complications in very elderly patient.

References:

Coker, E., Ploeg, J., Kaasalainen, S., & Carter, N. (2017). Observations of oral hygiene care interventions provided by nurses to hospitalized older people. Geriatric Nursing, 38(1), 17-21.

Emami, E., Almeida, F. R., Feine, J. S., Karp, I., Lavigne, G., & Huynh, N. (2014). The effect of nocturnal wear of complete dentures on sleep and oral health related quality of life: study protocol for a randomized controlled trial. Trials, 15(1), 358.

Higashiguchi, T., Ohara, H., Kamakura, Y., Kikutani, T., Kuzuya, M., Enoki, H., … & Maruyama, M. (2017). Efficacy of a New Post-Mouthwash Intervention (Wiping Plus Oral Nutritional Supplements) for Preventing Aspiration Pneumonia in Elderly People: A Multicenter, Randomized, Comparative Trial. Annals of Nutrition and Metabolism, 71(3-4), 253-260.

Iinuma, T., Arai, Y., Abe, Y., Takayama, M., Fukumoto, M., Fukui, Y., … & Komiyama, K. (2015). Denture wearing during sleep doubles the risk of pneumonia in the very elderly. Journal of dental research, 94(3_suppl), 28S-36S.

Jaiswal, M., Chaturvedi, T. P., Srivastava, G. N., Parihar, A. V., & Pratap, C. B. (2014). Poor oral dental hygiene and aspiration pneumonia. The Journal of Community Health Management, 1(1), 67-71.

Li, C., Zhang, Q., Ng, L., Needleman, I., Jie, L., & Walsh, T. (2016). Oral care measures for preventing nursing home?acquired pneumonia. The Cochrane Library.

Manabe, T., Teramoto, S., Tamiya, N., Okochi, J., & Hizawa, N. (2015). Risk factors for aspiration pneumonia in older adults. PLoS One, 10(10), e0140060.

Müller, F. (2015). Oral hygiene reduces the mortality from aspiration pneumonia in frail elders. Journal of dental research, 94(3_suppl), 14S-16S.

Ohara, H., Higashiguchi, T., Kuzuya, M., Kikutani, T., Sanada, H., Maruyama, M., … & Mori, N. (2016). SUN-P042: Efficacy of a New Intervention “Wiping Plus Providing Oral Nutritional Supplements” in Preventing Aspiration Pneumonia in Elderly People: A Multicenter, Randomized Comparative Trial. Clinical Nutrition, 35, S60.