Cees de Baat

Risk factors for aspiration pneumonia in frail older people: a systematic literature review

OBJECTIVE To systematically review the risks for aspiration pneumonia in frail older people and the contribution of bad oral health among the risk factors. DESIGN Systematic literature review. SETTING PubMed (Medline), Web of Science, Cochrane Library, EMBASE, and CINAHL were searched for eligible studies, published in English in the period January 2000 to April 2009. PARTICIPANTS Frail older people. MEASUREMENTS Only publications with regard to hospitalized, institutionalized, or frail home-dwelling people of 60 years and older were eligible. Two authors independently assessed the publications for their methodological quality. Unadjusted and adjusted odds ratios and their corresponding 95% confidence intervals for respective risk factors related to aspiration pneumonia were extracted. The results were evaluated according to the levels of evidence of the Oxford Centre for Evidence-based Medicine. RESULTS A total of 21 publications fulfilled the quality criteria. Evidence level 2a (systematic review with homogeneity of cohort studies) was found for a positive relationship between aspiration pneumonia and age, male gender, lung diseases, dysphagia, and diabetes mellitus; 2b (individual cohort study) for severe dementia, angiotensin I-converting enzyme deletion/deletion genotype, and bad oral health; 3a (systematic review with homogeneity of case-control studies) for malnutrition; 3b (individual case-control study) for Parkinsons disease and the use of antipsychotic drugs, proton pump inhibitors, and angiotensin-converting enzyme inhibitors. The contribution of bad oral health among the risk factors seems limited. CONCLUSION Thirteen significant risk factors were identified: age, male gender, lung diseases, dysphagia, diabetes mellitus, severe dementia, angiotensin I-converting enzyme deletion/deletion genotype, bad oral health, malnutrition, Parkinsons disease, and the use of antipsychotic drugs, proton pump inhibitors, and angiotensin-converting enzyme inhibitors. The contribution of bad oral health seems limited.

Oral health care and aspiration pneumonia in frail older people: a systematic literature review

OBJECTIVE To systematically review the literature on oral health care interventions in frail older people and the effect on the incidence of aspiration pneumonia. BACKGROUND Oral health care seems to play an important role in the prevention of aspiration pneumonia in frail older people. METHODS Pubmed, Web of Science, Cochrane Library, EMBASE and CINAHL were searched for eligible intervention studies. Only publications with regard to hospitalized or institutionalized older people, who were not dependent on mechanical ventilation were eligible. Two authors independently assessed the publications for their methodological quality. RESULTS Five publications were included and reviewed. Two studies showed that improvement of oral health care diminished the risk of developing aspiration pneumonia and the risk of dying from aspiration pneumonia directly. The three studies remaining showed that adequate oral health care decreased the amount of potential respiratory pathogens and suggested a reduction in the risk of aspiration pneumonia by improving the swallowing reflex and cough reflex sensitivity. CONCLUSIONS According to the results of the current systematic literature review oral health care, consisting of tooth brushing after each meal, cleaning dentures once a day, and professional oral health care once a week, seems the best intervention to reduce the incidence of aspiration pneumonia.

An international multicenter study on the effectiveness of a denture adhesive in maxillary dentures using disposable gnathometers

No consensus has been achieved on whether denture adhesives are beneficial adjuncts in denture-wearers management. The purpose of this international multicenter study was to determine objectively the effect of a denture adhesive (Kukident) on the retention of complete maxillary dentures using disposable gnathometers. The disposable gnathometers have a decimal scale for measuring the incisal force before dislodgement (= maximum incisal force) of maxillary dentures. The intra-observer reliability, the inter-observer reliability, and the linearity of the gnathometer units of the disposable gnathometers were examined in three pilot studies. Participants of the international multicentre main study were 88 patients who had been selected for complete maxillary denture treatment. The maximum incisal force of their previous and new denture without and with adhesive was measured using disposable gnathometers. The intra- and inter-observer reliability of the disposable gnathometers was very good, and there was a linear relation between the gnathometer units. The effect of the denture adhesive on the maximum incisal force of complete maxillary dentures was statistically significant in previous as well as new dentures, being more pronounced in previous than in new dentures.

Association of some specific nutrient deficiencies with periodontal disease in elderly people: A systematic literature review.

OBJECTIVE Deficiency of vitamin B complex, vitamin C, vitamin D, calcium, and magnesium has been associated with periodontal disease. This article systematically reviews the currently available literature on the feasible association of vitamin B complex, vitamin C, vitamin D, calcium, and magnesium deficiencies with periodontal disease in elderly people. METHODS We performed a systematic review of relevant English- and Dutch-language medical literature published from January 1990 to May 2007, with critical appraisal of those studies evaluating the association of vitamin B complex, vitamin C, vitamin D, calcium, and magnesium deficiencies with periodontal disease in elderly people. RESULTS None of the studies meeting the selection criteria included institutionalized elderly people. In the studies on non-institutionalized elderly people, no significant or consistent association was found between vitamin B complex, vitamin C, vitamin D, calcium, and magnesium dietary intakes and serum levels and periodontal disease. Although in those studies decreased dietary vitamin C intake was found to be associated with increased risk of periodontal disease, no conclusive evidence could be demonstrated. CONCLUSION There is no evidence of an association of vitamin B complex, vitamin C, vitamin D, calcium, and magnesium deficiencies with periodontal disease in non-institutionalized elderly people. To produce conclusive evidence on the subject of this systematic literature review, longitudinal cohort studies and follow-up randomized controlled trials are needed.

Poor oral health, a potential new geriatric syndrome.

This article presents a brief introduction to the medical aspects of ageing and age-related diseases, and to some geriatric syndromes, followed by a discussion on their impact on general and oral healthcare provision to community-dwelling older people. Recent investigations suggest that inflammation constitutes a biological foundation of ageing and the onset of age-related diseases. Multimorbidity and polypharmacy, together with alterations in pharmacokinetics and pharmacodynamics, make older people at risk of adverse medication reactions. A side effect of several medications is causing xerostomia and hyposalivation, and both the type and number of medications used are relevant. New options of general healthcare provision to community-dwelling older people are the use of mobility aids and assistive technology devices, domiciliary health care, respite care and telecare. Their oral health status may be jeopardised by frailty, disability, care dependency and limited access to professional oral health care. Recommendations for improvement are the following: better integrating oral health care into general health care, developing and implementing an oral healthcare guideline, providing customised oral hygiene care aids, domiciliary oral healthcare provision, visiting dental hygienists and/or nurses, oral hygiene telecare, easily and safely accessible dental offices, transforming dentistry into medical oral health care and upgrading dentists to oral physicians. In case oral healthcare providers do not take the responsibility of persuading society of the importance of adequate oral health, weakened oral health of community-dwelling older people will become a potential new geriatric syndrome.

An oral health care guideline for institutionalised older people.

Institutionalized older people are prone to oral health problems and their negative impact due to frailty, disabilities, multi-morbidity, and multiple medication use. Until recently, no evidence-based oral health care guideline for institutionalized older people has been available. For that reason, the Dutch Association of Nursing Home Physicians developed the Oral health care Guideline for Older people in Long-term care Institutions (OGOLI), meeting the requirements of the AGREE instrument for assessing a guidelines quality. This short report presents the keynotes and the content of the Oral health care Guideline. Most recommendations are based on expert opinions. Only 4 recommendations (education, pneumonia, use of an electric toothbrush, and fluoride rinsing in case of a sudden increase of oral plaque amount) are based on evidence level A2 conclusions. This emphasizes the need for further research on oral health of institutionalized older people.

Quantitative computed tomography bone mineral density measurements in irradiated and non‐irradiated minipig alveolar bone: an experimental study

OBJECTIVE The objective of this study was to analyse the effect of irradiation on bone mineral density (BMD). MATERIALS AND METHODS All maxillary and mandibular pre-molars and molars of six minipigs were extracted. After a 3-month healing period, the maxilla and mandibles of three minipigs received three irradiation exposures at a total dose of 24 Gy. At 3 months after irradiation, quantitative computed tomography (QCT) was performed. As a reference, a calibration bone phantom with pre-determined BMD was attached to the head of the minipigs. The QCT data were imported into a software program to calculate the BMD of the alveolar bone and the calibration bone phantom. In order to compare BMD values of individual minipigs, the so-called bone mineral density quotient (BMDQ) was created, dividing the BMD value of the alveolar bone by the BMD value of the calibration bone phantom. RESULTS Mean BMDQ values appeared to be higher in irradiated than in non-irradiated minipigs. However, the difference was not significant. In both irradiated and non-irradiated minipigs, the average mandibular BMDQ values were statistically significantly higher than the average maxillary BMDQ values (P=0.003). The P-values of the Student t-test, determining the irradiation effect, were 0.11 for maxillary, 0.14 for mandibular, and 0.07 for overall peri-implant BMDQ. P-values of the non-parametric Mann-Whitney test were all 0.05. CONCLUSION It could be concluded that, 3 months after irradiation, the BMD of irradiated alveolar minipig bone was increased, when compared with non-irradiated alveolar minipig bone. However, the increase was not statistically significant.

Intensity-modulated radiation therapy for oropharyngeal cancer: Radiation dosage constraint at the anterior mandible

Because the survival of endosseous implants in irradiated bone is lower than in non-irradiated bone, particularly if the irradiation dose exceeds 50Gy, a study was carried out to assess the irradiation dose in the anterior mandible, when intensity modulated radiation therapy (IMRT) is used. The hypothesis was that adequate IMRT planning in oropharyngeal cancer patients is allowing sufficiently low anterior mandibular bone radiation dosages to safely insert endosseous implants. Ten randomly selected patients with oropharyngeal cancer, primarily treated by intensity-modulated radiotherapy (IMRT), were included in this study. First, at five determined positions distributed over the anterior mandible, the appropriate radiation dosages were calculated according to the originally arranged fractionated radiation schedule. Second, for each patient an adjusted fractionated radiation schedule was established with an extra dose constraint which allowed a lower dose in the mandible taking into account that the anterior mandible needs protection against radiation-induced osteoradionecrosis. The goal for the adjusted fractionated radiation schedule was similar as that of the original fractionated radiation schedule, including a desired tumour target dosage of 70Gy and maximum mean local dosages for organs at risk. The data revealed a considerable and statistically significant, irradiation dose reduction in the anterior mandible without compromising the other constraints. As a result of this study it is strongly advised to maximize dose constraint to the anterior mandible when planning irradiation for oropharyngeal cancer patients, using IMRT. This would greatly facilitate successful implant treatment for this group of patients. The fractionated radiation schedules used, should also be used for the planning of the best implant positions by integrating them in the implant planning software.

Attitudes and usage of denture adhesives by complete denture wearers: a survey in Greece and the Netherlands.

OBJECTIVE To explore whether there are differences in usage of and attitudes towards denture adhesives among patients in two countries. BACKGROUND There are no multi-country surveys concerning usage of and attitudes towards denture adhesives from complete denture wearers. MATERIALS AND METHODS The survey took place in Greece and the Netherlands with a sample of 284 and 165 consecutive complete denture wearers, respectively, by using a 9-item prepared questionnaire. Statistical analysis relied on chi-square test at α = 0.05. RESULTS In this survey, 26 and 20% of Greek and Dutch patients, respectively, had tried denture adhesive, but only 27% of them in Greece as well as in the Netherlands currently used it; 49% of the Greek and 45% of the Dutch participants rated the overall performance of adhesives as good. Between the two populations, no differences were identified in a majority of the research variables, except where 27% of Greeks answered that they did not know the existence of denture adhesives compared to none of the Dutch patients and when 90% of the Dutch contrary to 70% of Greeks reported that they did not need denture adhesives as they could manage their dentures well. CONCLUSION The usage of and attitudes towards denture adhesives between the Greek and Dutch sample were similar with only two exceptions concerning the knowledge of existence and the need of using denture adhesives.

Effect of daily application of a 0.05% chlorhexidine solution on the incidence of (aspiration) pneumonia in care home residents: design of a multicentre cluster randomised controlled clinical trial

Introduction Pneumonia is an important cause of death in care home residents. Dysphagia and poor oral health are significant risk factors for developing aspiration pneumonia. Oral hygiene care reduces the number of oral bacteria and the risk of aspiration pneumonia. However, it is not clear yet which oral hygiene care intervention is most efficacious in reducing the risk of aspiration pneumonia. The aim of the study is to assess whether the application of a 0.05% chlorhexidine-containing solution in addition to the usual daily oral hygiene care reduces the incidence of pneumonia in physically disabled care home residents with dysphagia. Methods and analysis The study was designed as a multicentre cluster randomised controlled clinical trial, with care homes as units of randomisation. During 1 year, 500 physically disabled care home residents with dysphagia will be followed. The intervention consists of applying a 0.05% chlorhexidine-containing solution twice daily, immediately after the usual oral hygiene care, whereas the control group receives no application after the usual oral hygiene care. The primary outcome is the incidence of pneumonia diagnosed by a physician, using a set of strictly described criteria. The effect of the intervention on the incidence of pneumonia will be determined using a Cox regression analysis. The secondary outcomes are correlations between incidence of pneumonia, age, gender, diagnosed diseases, dysphagia severity, care dependency, actually used medication, number of teeth and implants present and the presence of removable dentures. Ethics and dissemination Ethical approval was obtained from the Medical Ethical Committee of Radboud university medical centre: NL.nr: 41990.091.12. Written and informed consent will be obtained from all participating care homes and residents. The studys findings will be published in peer-reviewed journals. Trial registration number The trial has been registered in the Netherlands in the National Trial Register: TC=3515.