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Look, Ma, No Pneumonia

Study: Supervised toothbrushing can prevent lung disease in elderly

TUESDAY, Nov. 13, 2001 (HealthDayNews) -- Keeping your breath fresh is a courtesy to others, but your own lungs might thank you for it, too.

Regular, supervised toothbrushing for people in nursing homes can significantly improve their swallowing reflex and may reduce the risk of getting potentially fatal pneumonia, a new study suggests.

The findings, appearing in the Nov. 14 issue of the Journal of the American Medical Association, aren't direct proof that better oral care indeed cuts the likelihood of respiratory infections in the elderly. And because they appear in a research letter, they don't carry as much weight as a full-blown study. But experts say the results do make a case for the connection between good oral hygiene and less pneumonia -- though not for the reasons the researchers argue.

Dr. Joseph Mylotte, a geriatric infectious disease expert at the University of Buffalo, says brushing should reduce the risk of pneumonia, but not because it helps people swallow. "The oral hygiene story theoretically should have nothing to do with the swallowing," Mylotte says. Rather, he explains, "it decreases the bacterial load in the oral pharynx, so when they do aspirate, they're aspirating less bacteria."

Although nursing home administrators claim their wards get adequate oral care, Mylotte, chief of infectious diseases at the Erie County Medical Center, disagrees. "There's pretty good solid evidence that oral hygiene is poor if you look at the existing literature."

Dr. Dan Meyer, director of science for the American Dental Association, says the elderly may suffer from poor oral health for several reasons, including their inability to hold a toothbrush and use floss. Many older people also take medications that hinder their ability to make saliva, which is key to flushing germs from the mouth, Meyer says.

A major problem for many elderly nursing home residents is dysphagia -- difficulty swallowing -- due to stroke, Alzheimer's disease, or other conditions. Patients with the disorder frequently aspirate their saliva, which, when the mouth isn't well cleaned, can be teeming with harmful bugs. If a patient is unable to adequately clear her lungs, the inhaled bacteria may trigger airway infections.

In earlier research, Dr. Akiko Yoshino and colleagues at Tohoku University School of Medicine in Sendai, Japan, showed that nursing home residents who received help with their oral hygiene over long periods suffered fewer bouts of pneumonia than did those left to brush on their own.

In the latest work, Yoshino's group sought to learn if the same was true over a shorter period of time.

For one month, they followed 40 elderly nursing home residents split evenly into two groups. Those in the first group, whose average age was 75, had their teeth and gums cleaned by home caregivers after each meal every day, using distilled water. Those in the second group, whose average age was 76, were left to perform their own teeth cleaning.

To see whether assisted brushing improved swallowing, the researchers tested the reflex by measuring how quickly the subjects swallowed after getting a small squirt of water injected up their nose.

Those who got help brushing saw their swallowing reflex times shorten significantly over the study period, the researchers say. And their scores on a standard list of activities of daily living (ADL) also improved compared with those who were left to clean their own teeth and gums.

Yoshino's group also found that those who received help brushing had a sharp rise in saliva levels of a molecule called substance P, a chemical released from nerve endings that has been linked to the swallowing response. That suggests "daily brushing stimulates sensory nerves in the oral cavity," they write.

Dr. Jean Chouinard, medical director at the Sisters of Charity of the Ottawa Health Service in Canada, says he's not convinced by the Japanese study.

"We think [oral care] is very, very important, just from perspective of quality of life," says Chouinard, who is familiar with the Japanese study. "If you can do that for them, it really, really helps. Does it reduce pneumonia? That's debatable."

Because aspiration is the cause of almost all cases of pneumonia -- even in young, healthy people for whom good dental habits are presumably more common -- oral hygiene's role in the disease is likely to be small, he says. Instead, Chouinard believes that the risk comes from an inability to expel aspirated fluids, a problem that's much more prevalent among the infirm elderly.

However, Chouinard has shown in his own research that improving the swallow reflex in dysphagic patients doesn't decrease their risk of pneumonia, although it lowers their chances of fatal aspiration.

What To Do

In a major report issued last year, the U.S. Surgeon General's office called mouth diseases a "silent epidemic" among Americans. For more on the findings of the report, try the National Institutes of Health.

Pneumonia is a killer, especially in vulnerable persons, like the elderly. Read about the problem at MultiMedia Health Care.

To learn more about the health problems of America's elderly, visit the government's Administration on Aging.

SOURCES: Interviews with Joseph Mylotte, M.D., professor of medicine, University of Buffalo and chief of infectious diseases, Erie County Medical Center, Buffalo; Dan Meyer, D.D.S., director of science, American Dental Association, Chicago; Jean Chouinard M.D., medical director, Ottawa Health Service, Sisters of Charity, Ottawa, Ontario; Nov. 14, 2001, Journal of the American Medical Association
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