Risk factors for postoperative pneumonia according to examination findings before surgery under general anesthesia

Association of Number of Oral bacteria with Ventilator-Associated Pneumonia and Delirium in Patients in the Intensive Care Unit

OBJECTIVES

Ventilator-associated pneumonia (VAP) and delirium are major complications among patients in the intensive care unit (ICU). The impact of oral bacterial count on these conditions is not well understood. This study aimed to explore the association between oral bacterial load and the incidence of VAP and delirium in ICU patients.

METHODS

In this single-center longitudinal study, 130 patients admitted to the ICU from September 2022 to May 2023 were included. Oral bacteria counts on the tongue were quantified, and assessments of oral health using the Oral Health Assessment Tool (OHAT) and oral moisture levels were also conducted. We examined the associations between oral bacterial count, OHAT scores, and oral moisture with the incidence of VAP and delirium.

RESULTS

The incidence rates of VAP and delirium were 31.4% and 35.4%, respectively. Patients with a high oral bacterial load (≥5.0 × 107 CFU/mL) at ICU admission had a higher likelihood of developing VAP (odds ratio [OR] 7.43, 95% confidence interval [CI] 1.68-32.87) and delirium (OR 3.30, 95% CI 1.04-10.44) compared with those with lower bacterial counts (<1.0 × 107 CFU/mL). No significant associations were found between OHAT scores and oral moisture and the occurrence of VAP or delirium.

CONCLUSION

A higher oral bacterial count at ICU admission was associated with increased incidences of VAP and delirium.

Association of remaining tooth number with postoperative respiratory complications in heart valve surgery patients

OBJECTIVES

This study examined the association between the number of remaining teeth and the incidence of postoperative respiratory complications in patients undergoing heart valve surgery.

METHODS

We retrospectively enrolled 157 patients who underwent heart valve surgery between April 2010 and March 2019. Data on patient characteristics including systemic and oral conditions were extracted and postoperative respiratory complications were set as outcomes. Patients were divided into two groups according to the number of remaining teeth (≥20, <20). After adjusting for confounding factors with propensity scoring, logistic regression analysis was performed to examine the association of remaining teeth number with the incidence of postoperative respiratory complications. In addition, subgroup analysis was performed by stratifying the data into quintiles based on the propensity score.

RESULTS

Univariate analysis showed significant differences between the two groups in factors, including age, past cardiac surgery experience, New York Heart Association functional classification class IV, denture use, tooth extraction before surgery, occlusal support, and periodontitis. Logistic regression analysis showed that patients with <20 remaining teeth had a significantly higher incidence of postoperative respiratory complications than those with ≥20 remaining teeth, with an odds ratio of 29.800 (p = 0.004). Subgroup analysis showed that the odds ratio for the patients with <20 remaining teeth was 9.000 (p = 0.038).

CONCLUSIONS

The results suggest that heart valve surgery patients shall get attention on oral disease prevention by dental care practitioners to maintain a sufficient number of teeth for the prevention of postoperative respiratory complications.

The Importance of Oral History: Does Dental Implant Placement or Caries One Year Before or After Primary Total Knee Arthroplasty Increase Medical Complications and Periprosthetic Joint Infections?

BACKGROUND

Consensus regarding prior dental problems on the outcomes of total knee arthroplasty (TKA) patients is lacking. Therefore, our objectives were to determine the association of dental caries or dental implant placement in TKA patients on the following: (1) medical complications; (2) health care utilization (lengths of stay and readmissions); (3) implant-related complications; and (4) expenditures.

METHODS

A retrospective query was performed using an administrative claims database for 3 patient cohorts undergoing primary TKA from 2010 to 2020. Patients who had a history of dental caries or implant placement 1 year prior to TKA (n = 1,466) and 1 year after TKA (n = 1,127) were case-matched to patients who did not have a dental history by age and comorbidities. Outcomes included 90-day complications, health care utilization parameters, 2-year implant complications, and expenditures. Logistic regression models computed odds ratios (OR) of complications and readmissions. P values less than 0.005 were significant.

RESULTS

Patients who had a dental implant placement prior to TKA had higher frequency of complications (20.05 versus 14.01%; OR: 1.53, P < .0001), including myocardial infarctions (2.52 versus 1.23%; OR: 2.08, P = .0002) and pneumonia (2.52 versus 1.24%; OR: 2.06, P = .0002). Lengths of stay (3.28 versus 2.98 days; P = .255), readmission rates (4.71 versus 4.28%; P = .470), and implant-related complications including periprosthetic joint infections (3.14 versus 2.63%; OR: 1.20, P = .279) were similar between patients lacking dental history. Expenditures were higher in patients who had a postoperative and preoperative dental history ($19,252 versus $19,363 versus 17,980; P < .001).

CONCLUSION

Dental caries or implant placement may reflect overall worse medical condition resulting in more complications and higher costs after TKA. Dental history screening preoperatively may assist arthroplasty surgeons in minimizing complications.

Incidence of Postoperative Pneumonia and Oral Microbiome for Patients with Cancer Operation

Postoperative pneumonia is a serious problem for patients and medical staff. In Japan, many hospitals introduced perioperative oral care management for the efficient use of medical resources. However, a high percentage of postoperative pneumonia still developed. Therefore, there is a need to identify the specific respiratory pathogens to predict the incidence of pneumonia The purpose of this study was to find out the candidate of bacterial species for the postoperative pneumonia. This study applied case-control study design for the patients who had a cancer operation with or without postoperative pneumonia. A total of 10 patients undergoing a cancer operation under general anesthesia participated in this study. The day before a cancer operation, preoperative oral care management was applied. Using the next generation sequence, oral microbiome of these patients was analyzed at the time of their first visit, the day before and after a cancer operation. Porphyromonas gingivalis and Fusobacterium nucleatum group can be a high risk at first visit. Atopobium parvulum and Enterococcus faecalis before a cancer operation can be a high risk. Poor oral hygiene increased the risk of incidence of postoperative pneumonia. Increased periodontal pathogens can be a high risk of the incidence of postoperative pneumonia. In addition, increased intestinal bacteria after oral care management can also be a high risk for the incidence of postoperative pneumonia.

Factors That Influence the Judgment of Oral Management Necessity in Preoperative Oral Screening

Oral management during the perioperative period is important to prevent the development of postoperative complications. However, there are no unified systems to examine the oral status of patients and very few studies have focused on preoperative oral screening. In this study, we examined the oral status of patients who underwent oral screening at a University Hospital. A total of 1173 patients who underwent oral screening for perioperative management from April 2020 to July 2021 were enrolled. The subjects’ medical data were retrospectively extracted from the dental records, and finally, the data of 1081 patients aged ≥20 years were analyzed. Oral screening based on seven categories was performed by dentists or dental hygienists. Our cumulative results determined whether patients required oral management during the perioperative period. “Poor oral hygiene” was the most frequent category (24%) of all oral categories examined. Logistic analysis revealed that tooth mobility had the highest odds ratio (21.476; 95% confidence interval: 11.462–40.239; p < 0.001) for oral management necessity during the perioperative period. Our study suggests that poor oral hygiene is most frequently observed in preoperative oral screening. Moreover, tooth mobility in preoperative oral screening may influence the judgment of oral management necessity during the perioperative period.

Effects of high versus low inspiratory oxygen fraction on postoperative clinical outcomes in patients undergoing surgery under general anesthesia: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

To determine whether high perioperative inspired oxygen fraction (FiO₂) compared with low FiO₂ has more deleterious postoperative clinical outcomes in patients undergoing non-thoracic surgery under general anesthesia.

DESIGN

Meta-analysis of randomized controlled trials.

SETTING

Operating room, postoperative recovery room and surgical ward.

PATIENTS

Surgical patients under general anesthesia.

INTERVENTION

High perioperative FiO₂ (≥0.8) vs. low FiO₂ (≤0.5).

MEASUREMENTS

The primary outcome was mortality within 30 days. Secondary outcomes were pulmonary outcomes (atelectasis, pneumonia, respiratory failure, postoperative pulmonary complications [PPCs], and postoperative oxygen parameters), intensive care unit (ICU) admissions, and length of hospital stay. A subgroup analysis was performed to explore the treatment effect by body mass index (BMI).

MAIN RESULTS

Twenty-six trials with a total 4991 patients were studied. The mortality in the high FiO₂ group did not differ from that in the low FiO₂ group (risk ratio [RR] 0.91, 95% confidence interval [CI] 0.42-1.97, P = 0.810). Nor were there any significant differences between the groups in such outcomes as pneumonia (RR 1.19, 95% CI 0.74-1.92, P = 0.470), respiratory failure (RR 1.29, 95% CI 0.82-2.04, P = 0.270), PPCs (RR 1.05, 95% CI 0.69-1.59, P = 0.830), ICU admission (RR 0.94, 95% CI 0.55-1.60, P = 0.810), and length of hospital stay (mean difference [MD] 0.27 d, 95% CI -0.28-0.81, P = 0.340). The high FiO₂ was associated with postoperative atelectasis more often (risk ratio 1.27, 95% CI 1.00-1.62, P = 0.050), and lower postoperative arterial partial oxygen pressure (MD -5.03 mmHg, 95% CI -7.90- -2.16, P < 0.001)_. In subgroup analysis of BMI >30 kg/m², these parameters were similarly affected between the groups.

CONCLUSIONS

The use of high FiO₂ compared to low FiO₂ did not affect the short-term mortality, although it may increase the incidence of atelectasis in adult, non-thoracic patients undergoing surgical procedures. Nor were there any significant differences in other secondary outcomes.

Impact of Working Environment on Job Satisfaction: Findings from a Survey of Japanese Dental Hygienists

In Japan, there is currently a shortage of dental hygienists. The number of dental hygienists as a workforce at dental clinical practice is not sufficient. Several factors affect career retention and job satisfaction of hygienists and these factors are considered to correlate with each other to construct networks. The aim of this study was to present a structural model of job satisfaction of Japanese dental hygienists and to determine the characteristics of unmotivated hygienists. The Japan Dental Hygienists’ Association has conducted a survey on their working environments every five years since 1981. Questionnaires were sent to all members of the association (16,113) and 8932 answers were returned. The data of 3807 active dental hygienists who worked at clinics were analyzed. Items associated with job satisfaction were derived from two latent variables, namely, the intrinsic psychosocial factors for the value of the work and extrinsic employment advantage. Based on the structural equation modeling, the association of value was higher than that of advantage. Most of the hygienists wished to continue working as dental hygienists. More than 60% felt their work required a high level of expertise. The value of the profession is deeply rooted in job satisfaction, motivation, and job retention of Japanese dental hygienists. Working environments where dental hygienists make great use of their specialized skills can lead to high career retention which prevent them from taking career breaks.

Dental Hygienists' Practice in Perioperative Oral Care Management According to the Japanese Dental Hygienists Survey 2019

Perioperative oral care management is effective in the prevention of postoperative complications, and dental hygienists play an important role. The aim of this study was to elucidate the practice and substantial role of dental hygienists in perioperative oral care management. The Japan Dental Hygienists Association conducted a survey of the employment status of Japanese dental hygienists in 2019. Questionnaires were distributed to all 16,722 members, and 8932 were returned (collection rate: 53.4%). A total of 3560 dental hygienists were working at dental clinics and 1450 (38.2%) were performing perioperative oral care management. More than 90% of them implemented conventional oral care practice. Less than half of the dental hygienists implemented treatment concerning oral functions. Only 9.9% of dental hygienists recognized shortened hospital stay as an effect of perioperative oral care management. Dental hygienists who implemented both nutritional instruction and training of swallowing function or mouth rinsing instructions recognized the shortened hospital stay effect. Overall implementation of perioperative oral care management led to shortened hospital stay. Implementation of perioperative oral care management required knowledge and skills related to systemic health conditions. A stepwise educational program is necessary for perioperative oral care management to become commonplace for dental hygienists.

Relationship between Oral Health Status and Postoperative Fever among Patients with Lung Cancer Treated by Surgery: A Retrospective Cohort Study

A retrospective observational study using an oral bacteria counter was conducted to evaluate the trends in the number of oral bacteria in the perioperative period of lung cancer patients and to verify the relationship between oral health status and postoperative fever. All patients received perioperative oral management (POM) by oral specialists between April 2012 and December 2018 at Kagawa Prefectural Central Hospital, Kagawa, Japan prior to lung cancer surgery. Bacteria counts from the dorsum of the tongue were measured on the day of pre-hospitalization, pre-operation, and post-operation, and background data were also collected retrospectively. In total, 441 consecutive patients were enrolled in the study. Bonferroni’s multiple comparison test showed significantly higher oral bacteria counts at pre-hospitalization compared to pre- and post-operation (p < 0.001). Logistic regression analysis showed that body mass index, performance status, number of housemates, number of teeth, and white blood cell count at pre-operation were significantly associated with postoperative fever. The study showed that POM can reduce the level of oral bacterial counts, that the risk of postoperative complications is lower with dentulous patients, and that appropriate POM is essential for prevent of complications. Therefore, POM may play an important role in perioperative management of lung cancer patients.

Analysis of oral risk factors for ventilator-associated pneumonia in critically ill patients

Objective

This a cross-sectional study to evaluate the association between oral health findings and ventilator-associated pneumonia (VAP) among critically ill patients in intensive care units (ICU).

Material and methods

Data were collected from medical records, and a detailed oral physical examination was performed on 663 critically ill patients on mechanical ventilation. Data were statistically analysed using univariate and logistic regression models relating the development of VAP with the oral findings.

Results

At oral physical examination, the most frequent findings were tooth loss (568–85.67%), coated tongue (422–63.65%) and oral bleeding (192–28.96%). Patients with a coated tongue or oral bleeding on the first day of ICU hospitalization developed more VAP than did patients without these conditions (20.14 vs 13.69%, p = 0.02; 23.44 vs 15.50%, p = 0.01, respectively). In the logistic regression, a coated tongue and oral bleeding were considered independent risk factors for VAP development (OR = 1.61 (1.03–2.51) and OR = 1.69 (1.08–2.66), respectively).

Conclusions

The presence of a coated tongue and oral bleeding in ICU admission could be considered markers for the development of VAP.

Clinical relevance

The results of this paper reinforce the importance of proper maintenance of oral hygiene before intubation, which may lead to a decrease in the incidence of VAP in the ICU.