By Jannette Whisenhunt, RDH, BS, MEd, PhD
Most of us have treated patients with respiratory issues such as asthma and chronic obstructive pulmonary disease (COPD). When we treat patients who have breathing issues, we remember that we have to sit them up a little more in case they have a difficult time lying flat in the chair. Another very common thing we are familiar with is that certain inhalers, particularly those that contain steroids, can cause oral fungal infections, so patients should always rinse their mouths out after inhaler use to decrease this chance. But did you know that there is an oral-systemic link between periodontal disease and some other serious respiratory issues? Periodontal disease bacteria may contribute to a higher risk of COPD in patients with respiratory depression and to a higher risk of pneumonia in patients who are hospitalized.
You know to teach patients to take care of their oral tissues, but do you discuss the potential of periodontal disease to impact their breathing issues? I don’t think many of us think of that when we are going over our patients’ medical histories. We should focus on it more, and we should look at the whole patient and all of his or her medical issues. As dental hygiene professionals, we need to increase our knowledge about the various inflammatory diseases our patients have in order to know how these disease processes may be aggravated with the bacteria from their periodontal disease.
Patients who have advanced respiratory issues are more susceptible to infections from periodontal disease bacteria.1 Several studies have examined whether periodontal disease correlates with a higher risk of COPD, and the results have been mixed.2 Many studies have verified that there is a direct link between periodontal disease bacteria and hospital-acquired pneumonia, an infection of the lungs contracted during a stay in the hospital or a long-term care facility.3
Periodontal disease bacteria can be aspirated into the lungs via saliva.4 If patients are not taking good care of their oral health while hospitalized, colonization of oral bacteria may put them at a higher risk of developing this pneumonia.5 Patients requiring an endotracheal tube are most susceptible, as the adjunctive airway provides a direct path into the lungs.
Ventilator-associated pneumonia (VAP), which is characterized by pneumonia development in a patient 48 hours or more after mechanical ventilation is initiated, and hospital-acquired pneumonia (HAP) both represent a significant burden for our health-care system. HAP has been shown to extend the length of a patient’s hospital stay by seven to nine days, increasing hospital cost by approximately $40,000 per patient.6 In fact, pneumonia accounts for approximately 15% of all hospital-acquired illnesses, and the United States spends almost $6.5 billion each year for treatment of patients suffering from pneumonia.7
As indicated previously, various oral decontamination techniques have been studied extensively with somewhat mixed results. A 2016 Cochrane review examined 38 trials evaluating the use of chlorhexidine, tooth brushing, and other oral care solutions.8 Use of chlorhexidine appeared to decrease the likelihood of VAP; however, there was no reduction in overall mortality, length of intensive care stay, or length of time receiving mechanical ventilation.8 While there is little to debate about the need for good oral hygiene among patients with respiratory conditions, further study is needed to determine best practices, particularly when taking into account primary outcome indicators.
Ultrasonic scaler use, air polishing, and coronal polishing are contraindicated for patients with several respiratory issues, due to the bacteria-laden aerosols and splatter that can be aspirated into the lungs. Nitrous oxide use for anxiety or pain control can also be a problem for any patient who has respiratory issues, due to upper respiratory obstruction or difficulty breathing through the nose.4
See the related chart, since it provides some pointers that may help you in treating your patients who have respiratory depression.
With any respiratory disease, there is always a risk of breathing problems or cessation, so we always need to be ready to treat an emergency. We need to ensure that we are comfortable with our office’s emergency kit and oxygen tank use. We need to recognize any respiratory distress and be prepared to manage the symptoms. How patients’ oral health may affect their respiratory disease is something that we can help our patients understand. Happy scaling!
Author’s note: John Sherman, MHS, BSRT, RRT-ACCS, RRT-NPS, RCP, has worked with me on this month’s article. He is the program coordinator of the Forsyth Technical Institute respiratory therapy program. I really appreciate his expertise in and advice about this field of medicine. RDH
References
1. Scannapieco FA, Mylotte JM. Relationships between periodontal disease and bacterial pneumonia. J Periodontol. 1996;67(10 Suppl):1114-1122.
2. Wang Z, Zhou X, Zhang J, et al. Periodontal health, oral health behaviours, and chronic obstructive pulmonary disease. J Clin Periodontol. 2009;36(9);750-755.
3. Limeback H. Implications of oral infections on systemic diseases in the institutionalized elderly with a special focus on pneumonia. Ann Periodontol. 1998;3(1):262-275.
4. Wilkins EM. Chapter 65: The Patient with a Respiratory Disease. Clinical Practice of the Dental Hygienist.11th ed. Philadelphia: Lippincott Williams & Wilkins; 2013.
5. El-Solh AA, Pietrantoni C, Bhat A, et al. Colonization of dental plaques: a reservoir of respiratory pathogens for hospital-acquired pneumonia in institutionalized elders. Chest. 2004;126(5):1575-1582.
6. Browne E, Hellyer TP, Baudouin SV, et al. A national survey of the diagnosis and management of suspected ventilator-associated pneumonia. BMJ Open Respir Res. 2014;1(1):e000066.
7. Kanzigg LA, Hunt L. Oral health and hospital-acquired pneumonia in elderly patients: a review of the literature. J Dent Hyg. 2016;90(Suppl 1):15-21.
8. Hua F, Xie H, Worthington HV, Furness S, Zhang Q. LI C. Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia. Cochrane Database Syst Rev. 2016;10:CD008367.
Jannette Whisenhunt, RDH, BS, MEd, PhD, is the Department Chair of Dental Education at Forsyth Technical Community College in Winston-Salem, N.C. Dr. Whisenhunt has taught since 1987 in the dental hygiene and dental assisting curricula. She has a love for students and served as the state student advisor for nine years and has won the student Advisor of the Year award from ADHA in the past. Her teaching interests are in oral cancer, ethics, infection control, emergencies and orofacial anatomy. Dr. Whisenhunt also has a small continuing education business where she provides CE courses for dental practices and local associations. She can be reached at [email protected].
