Effects of oral care with tongue cleaning on coughing ability in geriatric care facilities: a randomised controlled trial

Oral care measures for preventing nursing home-acquired pneumonia

BACKGROUND

Pneumonia in residents of nursing homes can be termed nursing home-acquired pneumonia (NHAP). NHAP is one of the most common infections identified in nursing home residents and has the highest mortality of any infection in this population. NHAP is associated with poor oral hygiene and may be caused by aspiration of oropharyngeal flora into the lung. Oral care measures to remove or disrupt oral plaque might reduce the risk of NHAP. This is the first update of a review published in 2018.

OBJECTIVES

To assess effects of oral care measures for preventing nursing home-acquired pneumonia in residents of nursing homes and other long-term care facilities.

SEARCH METHODS

An information specialist searched CENTRAL, MEDLINE, Embase, one other database and three trials registers up to 12 May 2022. We also used additional search methods to identify published, unpublished and ongoing studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that evaluated the effects of oral care measures (brushing, swabbing, denture cleaning mouthrinse, or combination) in residents of any age in nursing homes and other long-term care facilities.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed search results, extracted data, and assessed risk of bias in the included studies. We contacted study authors for additional information. We pooled data from studies with similar interventions and outcomes. We reported risk ratios (RRs) for dichotomous outcomes, mean differences (MDs) for continuous outcomes, and hazard ratios (HRs) or incidence rate ratio (IRR) for time-to-event outcomes, using random-effects models.

MAIN RESULTS

We included six RCTs (6244 participants), all of which were at high risk of bias. Three studies were carried out in Japan, two in the USA, and one in France. The studies evaluated one comparison: professional oral care versus usual oral care. We did not include the results from one study (834 participants) because it had been stopped at interim analysis.  Consistent results from five studies, with 5018 participants, provided insufficient evidence of a difference between professional oral care and usual (simple, self-administered) oral care in the incidence of pneumonia. Three studies reported HRs, one reported IRRs, and one reported RRs. Due to the variation in study design and follow-up duration, we decided not to pool the data. We downgraded the certainty of the evidence for this outcome by two levels to low: one level for study limitations (high risk of performance bias), and one level for imprecision. There was low-certainty evidence from meta-analysis of two individually randomised studies that professional oral care may reduce the risk of pneumonia-associated mortality compared with usual oral care at 24 months' follow-up (RR 0.43, 95% CI 0.25 to 0.76, 454 participants). Another study (2513 participants) reported insufficient evidence of a difference for this outcome at 18 months' follow-up. Three studies measured all-cause mortality and identified insufficient evidence of a difference between professional and usual oral care at 12 to 30 months' follow-up. Only one study (834 participants) measured the adverse effects of the interventions. The study identified no serious events and 64 non-serious events, the most common of which were oral cavity disturbances (not defined) and dental staining. No studies evaluated oral care versus no oral care.

AUTHORS' CONCLUSIONS

Although low-certainty evidence suggests that professional oral care may reduce mortality compared to usual care when measured at 24 months, the effect of professional oral care on preventing NHAP remains largely unclear. Low-certainty evidence was inconclusive about the effects of this intervention on incidence and number of first episodes of NHAP. Due to differences in study design, effect measures, follow-up duration, and composition of the interventions, we cannot determine the optimal oral care protocol from current evidence.  Future trials will require larger samples, robust methods that ensure low risk of bias, and more practicable interventions for nursing home residents.

Tongue cleaning in the elderly and its role in the respiratory and swallowing functions: Benefits and medical perspectives

Oral dysfunction, including oral uncleanness and decline in tongue motor function, tongue pressure and swallowing function, precedes frailty. The tongue's dorsum is a reservoir of oral microbiota, desquamated epithelial mucosa and leukocytes due to the multi-papillate anatomy, and leads to tongue coating. The tongue coating is frequently found in older adults because of hyposalivation, immunity's hypoactivity, diminished motor function and compromised tongue's pressure with age. Anaerobe-driven volatile sulphur compounds in tongue coating are a major cause of intra-oral malodor. Dysbiosis of the tongue-coating microbiome rather than the amount of microorganisms is associated with a risk of aspiration pneumonia. Daily tongue cleaning with a brush or scraper is an easy way to control tongue coating deposits and quality. Using mouth wash or rinse-containing germicides is also a way to control the microbiota of tongue coating. The tongue function is closely related to swallowing. Tongue and suprahyoid muscles are linked with respiratory muscles through the endothoracic fascia. The mechanical stimulation during the cleaning of the tongue may stimulate the respiratory muscles. An intervention trial revealed that tongue cleaning by mucosal brush improves tongue pressure, swallowing and respiratory function in old residents of nursing homes, suggesting a rehabilitative effect of tongue cleaning on the swallowing and respiratory functions, preventing aspiration pneumonia. This narrative review assesses the tongue-cleaning benefits for respiratory and swallowing functions and the possibility of preventing aspiration pneumonia.

Hospital Dentistry for Intensive Care Unit Patients: A Comprehensive Review

This study aimed to review the oral hygiene status, oral care guidelines, and outcomes of oral care in intensive care unit (ICU) patients from a dental perspective for effective oral care. A literature search using the keywords "Hospital dentistry" OR "Oral care" OR "Intensive care unit" OR "Hospital inpatient" OR "Hospitalization" OR "Emergency service" AND "Oral health" OR "Oral hygiene" OR "Dental plaque" was conducted in PubMed, Medline, and Google Scholar to identify publications reporting on the oral care of the patients admitted to ICUs. A total of 17,400 articles were initially identified. Of these, 58 were selected and classified into three categories for critical review. Seven of these studies evaluated the oral status of ICU patients, and most of the studies indicated that ICU patients had poor oral hygiene or required active dental treatment. Thirty-three of these studies evaluated oral care methods for ICU patients, and in general, oral care methods using chlorhexidine as adjuncts along with tooth brushing were recommended. However, there were insufficient studies to evaluate oral hygiene through effective assessment tools from a dental perspective. In 36 studies on the outcomes of oral care in ICU patients, interventions by dental professionals showed effective results in preventing hospital-acquired infection. This review highlights the importance of establishing guidelines for the evaluation of oral status in ICU patients and summarizes data that may be useful for future studies. Further studies on maintaining good oral hygiene among ICU patients are needed.

Tongue cleaning maintains respiratory function in older individuals: A 1-year randomised controlled trial

OBJECTIVE

The aim of this 1-year longitudinal randomised controlled trial was to evaluate the effectiveness of tongue cleaning on the maintenance of respiratory function in older adults requiring care.

METHODS

The participants included 24 residents of two nursing homes in Kitakyushu, Japan. The participants were randomised to receive tongue cleaning with routine oral care (intervention group, n = 12), or routine oral care alone (control group, n = 12). Among the participants, three in the intervention group and four in the control group had cerebrovascular disease history, four in the intervention group and four in the control group had a history of cardiac disease, and five in the intervention group and four in the control group were without medical history. Respiratory function was assessed on the basis of the peak expiratory flow rate (PEFR). Tongue pressure, swallowing function, oral health status, activities of daily living and nutritional status were also measured at baseline and at the end of the 1-year follow-up period.

RESULTS

The number of analysed participants in each group was 12. In the control group, the PEFR (1.6 [0.4-4.2] L s^-1 vs 1.4 [0.4-3.2] L s^-1 , P = .034) and tongue pressure (16.4 [1.7-35.2] kPa vs 8.0 [1.4-38.6] kPa, P = .032) significantly declined after 1-year. However, the PEFR (1.5 [0.8-2.9] L s^-1 vs 1.6 [0.7-4.2] L s^-1 , P = .366) and tongue pressure (18.1 [4.2-37.1] kPa vs 16.1 [5.2-41] kPa, P = .307) were maintained in the intervention group. The change in the PEFR was significantly greater in the intervention group compared with the control group (0.130 [-0.45-1.70] L s^-1 vs -1.70 [-10.00-10.00] L s^-1 , P = .028).

CONCLUSION

Our findings suggest that tongue cleaning may help maintain tongue and respiratory function in older adults requiring care.

Development of a European consensus from dentists, dental hygienists and physicians on a standard for oral health care in care-dependent older people: An e-Delphi study

OBJECTIVES

This study aimed to obtain a consensus on oral health policy, access to dental care, oral hygiene measures and training levels.

BACKGROUND

Poor oral health is widespread in care-dependent older people, but no consensus for a minimum standard of oral health care exists yet.

METHODS

The e-Delphi approach was applied to a selected panel of interdisciplinary experts. Data analysis was based on three measurements: (a) ≥70% of experts' opinion fall into category "agree or strongly agree," (b) median score on the 5-point Likert scale ≥4, (c) interquartile range ≤1.

RESULTS

A total of 31 experts from 17 European countries participated in this survey. Agreement was achieved for a compulsory dental examination when an elder is admitted to a long-term care (LTC) facility. Older people should brush their teeth twice/day and regularly clean interproximal spaces and oral mucosa. Dentures should be rinsed after meals and cleaned twice/day. The use of denture cleansing tablets was considered necessary. Dentures should be removed before sleeping and stored dry. A 5000 ppm fluoride toothpaste should be applied daily in elder with high caries risk. A short report on the oral health status of the elder should be included in the geriatric assessment. All experts concluded that the knowledge and the training in oral health care for caregivers and family members of care-dependent older people were imperative.

CONCLUSIONS

Using the e-Delphi method, multidisciplinary healthcare professionals from different countries agreed on certain cardinal recommendations for a standard oral health care for care-dependent older people.

Interventions to improve oral health of older people: A scoping review

OBJECTIVES

A range of interventions have been tested to improve oral health of older people. We performed a scoping review to map interventions' aims, outcome measures and findings, and to locate them on different levels of care.

DATA

We systematically screened for (1) controlled studies on (2) people over 65 years of age, (3) comparing at least two interventions to improve oral health. Interventions were summarized according to their aims and the employed intervention type, mapped on their level of action, and classified as primary/secondary/tertiary prevention.

SOURCES

Studies retrieved via MEDLINE, EMBASE, CINAHL.

STUDY SELECTION

Eighty-one studies (published 1997-2019, conducted mainly in high-income countries) were included. Sample sizes varied (n = 24-1987). Follow-up was 0.25-60 months. Most studies (64/81) found a statistically significant benefit of the intervention. A total of 13 different aims were identified, and a range of intervention types employed (e.g. educational interventions, professional oral healthcare, restorative treatment, fluoride application and, generally, dentifrices, mouthwashes, chewing gums/food supplements). Most studies were located on the carer/patient level (56/81 studies) or the system/policy-maker level (44/81). The majority of studies aimed for primary prevention (64/81).

CONCLUSIONS

Oral health improvement interventions are widely studied. However, study aims, methods and outcome measures are highly heterogeneous, which limits the ability for robust conclusions. Current research focusses on primary prevention on the level of patients/carers or system/policy-maker level. Future studies may want to consider interventions on dentists' level focussing on secondary prevention. These studies should rely on a core set of comprehensive, standardized set of outcome measures.

CLINICAL SIGNIFICANCE

While specific interventions seem efficacious to improve older people's oral health, the current body of evidence is neither comprehensive (significant gaps exists in relevant levels of the care process) nor comparable enough to draw robust conclusions.

Impact of Tongue Pressure and Peak Expiratory Flow Rate on Nutritional Status of Older Residents of Nursing Homes in Japan: A Cross-Sectional Study

OBJECTIVES

Swallowing function is critical for continuing oral feeding to prevent frailty in older adults. In this study, we investigated the impact of tongue pressure and pulmonary function on the nutritional status of older adults.

DESIGN, SETTING, PARTICIPANTS

This cross-sectional study was conducted in Kitakyushu, Japan from August 2017 to November 2018. Fifty-two residents aged >65 years of age from three nursing care insurance facilities in Kitakyushu City, Japan were recruited.

MEASUREMENTS

Oral health status, swallowing function, nutritional status using a mini nutritional assessment short form (MNA-SF), cognitive function, activities of daily living, peak expiratory flow rate (PEFR) for pulmonary function, and tongue pressure were assessed. The associations between nutritional status and the above factors were analysed using a logistic regression model.

RESULTS

Participants were divided into two groups: well-nourished group (MNA-SF ≤12) and undernutrition group (MNA-SF <12). Multivariate logistic regression analysis revealed that the correlations of PEFR [odds ratio (OR) = 0.23, 95% confidence interval (CI) = 0.23-0.89 p=0.033) and tongue pressure (OR = 0.88, 95% CI = 0.88-0.99, p=0.029) remained significant even after adjustment with possible confounders.

CONCLUSION

Maximum tongue pressure and PEFR in older adults were significantly associated with their nutritional status. These findings suggest that maintaining oral and pulmonary function may be a preventive factor against a decrease in the nutritional status of older frail adults.

Prevalence of Tongue Cleaning Using a Toothbrush: A Questionnaire Survey in Fukui Prefecture, Japan

Objective

The aim of this study was to investigate the tongue cleaning habits using toothbrushes among outpatients of the University of Fukui Hospital and a private hospital in Fukui Prefecture.

Methods

We administered a questionnaire survey to volunteers detailing tongue cleaning habits using toothbrushes. The content of the questions in this survey were as follows: gender, age, frequency of tongue cleaning, portion of tongue cleaning, and purposes of tongue cleaning.

Results

We had 1,014 volunteers of various ages participating in this study. Regarding the frequency of tongue cleaning, 187 (18.4%) of all participants replied, “Every day”, and 346 (34.1%) replied, “Sometimes”. Regarding tongue cleaning of the 533 participants with active tongue cleaning habits, 242 (45.4%) participants replied, “The center of the dorsum of the tongue”, and 274 (51.4%) replied, “The entire tongue”. When analyzing the purpose of tongue cleaning, 346 (64.9%) participants replied, “To remove the tongue stain”, 192 (36.0%) participants replied, “To remove the tongue coating”, and 240 (45.0%) participants replied, “To manage halitosis”.

Conclusions

This study clarified that a wide range of age groups in the nonhospitalized general public practiced tongue cleaning habits using a toothbrush for various purposes.

Motivational interviewing and oral health education: Experiences from a sample of elderly individuals in North and Northeast Philadelphia

BACKGROUND

Health education has a focus on knowledge dissemination and advice giving, which seldom translates into behavioral changes. Motivational interviewing (MI) has potential for helping elderly patients. However, most oral health studies conducted to date have excluded older individuals, and the outcomes examined have been exclusively clinical. This study examines the treatment fidelity of an individual-based MI intervention and assesses baseline characteristics related to older adults' self-efficacy (SE), oral-health-related quality of life (OHRQoL), oral health knowledge, and facilitators, barriers, and confidence on achieving MI goals.

METHODS

A convenience sample of 60 seniors was recruited. Participants were obtained through the flow of patients at dental clinics, and received a 45-min individual-based MI education session during a scheduled dental appointment.

RESULTS

Regarding MI treatment fidelity, basic proficiency or higher was achieved in all global areas. Significant correlations were found between SE and OHRQoL scores and rating elements of the MI intervention (P = 0.0001). Lack of knowledge related to connections between poly pharmacy and caries risk, and the importance of use of fluorides were evident.

CONCLUSION

Findings from the study support the reliability of this new MI intervention. Dental professionals are encouraged to adopt the spirit of MI in their one-on-one patient counseling.

Oral care measures for preventing nursing home-acquired pneumonia

BACKGROUND

Pneumonia occurring in residents of long-term care facilities and nursing homes can be termed 'nursing home-acquired pneumonia' (NHAP). NHAP is the leading cause of mortality among residents. NHAP may be caused by aspiration of oropharyngeal flora into the lung, and by failure of the individual's defence mechanisms to eliminate the aspirated bacteria. Oral care measures to remove or disrupt oral plaque might be effective in reducing the risk of NHAP.

OBJECTIVES

To assess effects of oral care measures for preventing nursing home-acquired pneumonia in residents of nursing homes and other long-term care facilities.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 15 November 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2017, Issue 10), MEDLINE Ovid (1946 to 15 November 2017), and Embase Ovid (1980 to 15 November 2017) and Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1937 to 15 November 2017). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. We also searched the Chinese Biomedical Literature Database, the China National Knowledge Infrastructure, and the Sciencepaper Online to 20 November 2017.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that evaluated the effects of oral care measures (brushing, swabbing, denture cleaning mouthrinse, or combination) in residents of any age in nursing homes and other long-term care facilities.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed search results, extracted data, and assessed risk of bias in the included studies. We contacted study authors for additional information. We pooled data from studies with similar interventions and outcomes. We reported risk ratio (RR) for dichotomous outcomes, mean difference (MD) for continuous outcomes, and hazard ratio (HR) for time-to-event outcomes, using random-effects models.

MAIN RESULTS

We included four RCTs (3905 participants), all of which were at high risk of bias. The studies all evaluated one comparison: professional oral care versus usual oral care. We did not pool the results from one study (N = 834 participants), which was stopped at interim analysis due to lack of a clear difference between groups.We were unable to determine whether professional oral care resulted in a lower incidence rate of NHAP compared with usual oral care over an 18-month period (hazard ratio 0.65, 95% CI 0.29 to 1.46; one study, 2513 participants analysed; low-quality evidence).We were also unable to determine whether professional oral care resulted in a lower number of first episodes of pneumonia compared with usual care over a 24-month period (RR 0.61, 95% CI 0.37 to 1.01; one study, 366 participants analysed; low-quality evidence).There was low-quality evidence from two studies that professional oral care may reduce the risk of pneumonia-associated mortality compared with usual oral care at 24-month follow-up (RR 0.41, 95% CI 0.24 to 0.72, 507 participants analysed).We were uncertain whether or not professional oral care may reduce all-cause mortality compared to usual care, when measured at 24-month follow-up (RR 0.55, 95% CI 0.27 to 1.15; one study, 141 participants analysed; very low-quality evidence).Only one study (834 participants randomised) measured adverse effects of the interventions. The study identified no serious events and 64 non-serious events, the most common of which were oral cavity disturbances (not defined) and dental staining.No studies evaluated oral care versus no oral care.

AUTHORS' CONCLUSIONS

Although low-quality evidence suggests that professional oral care could reduce mortality due to pneumonia in nursing home residents when compared to usual care, this finding must be considered with caution. Evidence for other outcomes is inconclusive. We found no high-quality evidence to determine which oral care measures are most effective for reducing nursing home-acquired pneumonia. Further trials are needed to draw reliable conclusions.

Effectiveness of Oral Rinsing Solutions on Mucus, Odor, and Plaque in the Hospitalized Elderly in Taiwan

This quasi-experimental and pretest-posttest study was conducted in Taiwan. The effectiveness of three types of oral rinsing solutions (normal saline, 0.2% chlorhexidine [CHX], and boiled water) was compared among 120 elderly patients (40 patients per group). Data on oral mucus, odor, and plaque were collected at admission on Day 1 (Time [T] 0), Day 4 (T1), Day 7 (T2), and Day 10 (T3). The results showed that the oral health condition in terms of mucus, plaque, and odor improved significantly over time. The effect for the oral condition did not differ significantly among the three groups, except for oral odor. At T2, the CHX group experienced higher oral odor than did the boiled water group (Solutions × Time interaction, F = 3.967, p = .002). Boiled water appears to be a safe and effective oral rinsing solution for hospitalized elderly patients.

The effect of a daily application of a 0.05% chlorhexidine oral rinse solution on the incidence of aspiration pneumonia in nursing home residents: a multicenter study

BACKGROUND

Dysphagia and potential respiratory pathogens in the oral biofilm are risk factors for aspiration pneumonia in nursing home residents. The aim of the study was to examine if the daily application of 0.05% chlorhexidine oral rinse solution is effective in reducing the incidence of aspiration pneumonia in nursing home residents with dysphagia. Associations between background variables (age, gender, dysphagia severity, care dependency, medication use, number of medical diagnoses, teeth and dental implants, and wearing removable dentures) and the incidence of aspiration pneumonia were also examined.

METHODS

This study is a multicenter study in which for 1 year participants with dysphagia in the intervention group received the usual oral hygiene care with the addition of a 0.05% chlorhexidine oral rinse solution, whereas participants in the control group received only oral hygiene care.

RESULTS

Data of 103 participants in 17 nursing homes were analyzed. Survival analysis showed no significant difference in the incidence of pneumonia between both groups (Cox regression, HR = 0.800; 95% CI [0.368-1.737], p = 0.572). Cox regression analysis for Functional Oral Intake Scale (FOIS)-level showed a significant risk of the incidence of pneumonia (HR = 0.804; 95% CI [0.656-0.986], p = 0.036). After adjustment for Group and FOIS-level, Cox multivariate proportional hazard regression analysis showed that the variables age, gender, Care-dependency Scale-score (CDS) number of diseases, medication use, number of teeth, and the presence of dental implants or removable dentures were not significantly associated with the incidence of pneumonia.

CONCLUSIONS

Chlorhexidine oral rinse solution 0.05% as an adjunctive intervention in daily oral hygiene care was not found to reduce incidence of aspiration pneumonia. The requested number of participants to achieve sufficient power was not established and high drop-out rate and non-structural compliance was present. The power was considered to be sufficient to analyze the associations between the background variables and the incidence of pneumonia in the included nursing home residents with dysphagia. Dysphagia was found to be a risk factor for aspiration pneumonia.

TRIAL REGISTRATION

Registration in The Netherlands National Trial Register: TC = 3515. Approval for the study was obtained from the Medical Ethical Committee of the Radboud University Medical Center (NL. nr:41,990.091.12).