Oral Health has been Associated with Some Respiratory Diseases
Respiratory diseases account for one in six deaths in the United States, making them collectively the third most common killer of Americans.1 A growing body of research has established an association between oral health and some respiratory diseases. Three systematic literature reviews in recent years suggest that the oral cavity may provide a reservoir for pulmonary pathogens.2-4 Furthermore, all three reviews concluded that oral hygiene procedures lower the risk of lung disease among elderly institutionalized individuals. One review presented evidence of the highest rating (I-A) in support of oropharyngeal decontamination to reduce the occurrence or progression of respiratory diseases.2 Another review pointed to strong evidence that mechanical oral hygiene decreases mortality risk from pneumonia; indeed approximately one in 10 cases of death from pneumonia among dependent elderly patients may be prevented by such measures.4 The third review suggested that oral interventions may lower the incidence of respiratory diseases among the institutionalized elderly at highest risk.3
Although the link has not been proven to be causal, there are two mechanisms that could explain such a relationship. First, dental plaque biofilm harbors both periodontal and pulmonary pathogens.1 That is of particular importance for patients in intensive care who are mechanically ventilated. Mechanical ventilation has a strong association with pneumonia, and recent work has demonstrated that bacterial isolates from dental plaque are genetically indistinguishable from those cultured from bronchoalveolar lavage of ventilated patients.5 Secondly, enzymes associated with periodontal disease and the pathogens that cause it may facilitate adherence of respiratory pathogens to airways while also destroying protective salivary pellicles, in turn reducing non-specific host defense mechanisms.2 In addition, cytokines released from the periodontium and carried with aspirated saliva of high-risk patients could upregulate expression of mucosal surface adhesion receptors, further potentiating pathogen colonization.2
Oral Hygiene for At-Risk Patients
Specific interventions shown to reduce nosocomial respiratory tract infections include frequent tooth brushing and the preoperative use of 0.12% or 0.2% chlorhexidine mouthrinse or gel.4 This illustrates the potential for elevated dental hygiene care to reduce the frequency of respiratory infections among patients most at risk for respiratory diseases. Such patients at risk, including smokers and patients with current acute or chronic respiratory conditions such as chronic obstructive pulmonary disease (COPD), should be considered for more frequent and intensive dental hygiene care. Other important risk factors for respiratory disease, particularly pneumonia, include female gender, advanced age, other diseases (i.e., diabetes or congestive heart failure), and immune suppression (i.e., among people with HIV or undergoing cancer therapy).1 It is worth noting that smoking is a risk factor common to both COPD and periodontitis.6
It has been established that oral hygiene intervention significantly reduces the occurrence of pneumonia in institutionalized subjects.2,3 Thus, dental hygienists who complete a thorough oral health assessment of their patients most at risk for respiratory diseases are well positioned to identify and address threats to good oral health, and potentially to reduce both the initiation and severity of common respiratory infections.1 Heightened oral hygiene care involving higher frequency visits is therefore warranted for at-risk patients. However, because aspiration of bacteria-bearing particulates from the mouth is especially dangerous in this group, procedures may need to be tailored. For example, debridement with ultrasonic instrumentation should be accompanied by high volume evacuation.6
Teamwork
The association between oral and respiratory health is another example of how dental care may effectively extend well beyond the mouth. It shows how critical a role dental hygienists may play beyond their traditional arena of care by working with caregivers, nurses, and other healthcare professionals to increase not only oral health, but general health as well.1
References
1. Gluch JI. Exploring the connection. The relationship between respiratory diseases and oral health. Dimensions Dent Hyg 2009;7(10):54-57.
2. Azarpazhooh A, Leake JL. Systematic review of the association between respiratory diseases and oral health. J Periodontol 2006;77(9):1465- 1482.
3. Scannapieco FA, Bush RB, Paju S. Associations between periodontal disease and risk for nosocomial bacterial pneumonia and chronic obstructive pulmonary disease. A systematic review. Ann Periodontol 2003;8(1):54-69.
4. Sjogren P, Nilsson E, Forsell M, Johansson O, Hoogstraate J. A systematic review of the preventive effect of oral hygiene on pneumonia and respiratory tract infection in elderly people in hospitals and nursing homes: effect estimates and methodological quality of randomized controlled trials. J Am Geriatr Soc 2008;56(11):2124-2130.
5. Heo SM, Haase EM, Lesse AJ, Gill SR, Scannapieco FA. Genetic relationships between respiratory pathogens isolated from dental plaque and bronchoalveolar lavage fluid from patients in the intensive care unit undergoing mechanical ventilation. Clin Infect Dis 2008;47(12):1562-1570.
6. Agado B, Bowen DM. Does the link between COPD and periodontitis affect dental hygiene treatment? Access 2009;23(4):19-21.