Will Maintenance of Oral Hygiene in Nursing Home Residents
Joseph M. Mylotte, MD
This article is an evaluation of the literature on oral
hygiene as a risk factor for nursing home–associated pneu-
monia (NHAP) and with interventions to improve oral
hygiene and reduce the incidence of NHAP. The back-
ground for this article is that studies that have evaluated
interventions to improve oral hygiene and prevent NHAP
have conﬂicting results. To try to understand the reason
for these results, the objective was to examine risk factor
and intervention studies and determine their methodologi-
cal validity. Review of studies evaluating oral hygiene sta-
tus as a risk factor for NHAP found multiple
methodological problems, resulting in limited evidence to
support this association. Studies of intervention methods,
whether ﬁnding beneﬁt or not in preventing NHAP, all
had methodological limitations. Therefore, it is unclear
whether oral hygiene is a risk factor for NHAP and
whether improving oral hygiene decreases the incidence of
this infection. A recommendation is made that future stud-
ies should carefully deﬁne the etiology of suspected NHAP
using molecular techniques when evaluating methods to
prevent this infection because viral pneumonia and aspira-
tion pneumonitis may mimic bacterial pneumonia even
though, at times, there may be coinfection with bacteria.
In this latter situation, improving oral hygiene may not
prevent pneumonia. Therefore, viral infection and pneu-
monitis with or without bacterial coinfection need to be
excluded so that the focus is on prevention of bacterial
pneumonia. J Am Geriatr Soc 0:1–5, 2017.
Key words: oral hygiene; pneumonia; nursing home;
long-term care; prevention
n 1988, it was hypothesized that poor oral hygiene may
be a risk factor for nursing home–associated pneumonia
(NHAP) and that improving oral hygiene in nursing home
residents might reduce the incidence of pneumonia and
death related to this infection.
The implication was that
poorly controlled dental plaque or periodontal abnormali-
ties were a reservoir for bacteria that cause pneumonia.
identiﬁed poor oral hygiene in
nursing home residents. Microbiological studies of dental
plaque in nursing home residents demonstrated high con-
centrations of gram-negative bacilli and Staphylococcus
aureus, which are potential etiological agents of pneumo-
The potential pathogenetic pathway to pneumonia
related to poor oral hygiene was described as follows: bac-
teria in plaque are in a bioﬁlm on teeth and are released
into saliva, which may be aspirated into the lower respira-
tory tract, and in the absence of effective host defenses in
the respiratory tract, pneumonia can develop.
Between 1993 and 2005, studies reported that poor
oral hygiene was a potential risk factor for NHAP.
Studies evaluating various methods to improve oral
hygiene in nursing home residents with the goal of reduc-
ing the incidence of pneumonia followed,
results of these studies
were contradictory, as will be
reviewed in a later section. To understand the contradic-
tory outcomes, it is necessary to examine carefully the
methodology of risk factor and intervention studies related
to NHAP. Therefore, the objective of this report was to
evaluate the methodology of studies examining oral
hygiene as a risk factor for NHAP and of clinical trials
reporting the effect of improving oral hygiene on develop-
ment of NHAP. The results of this analysis may inform
the design of future studies to prevent NHAP.
The studies selected for inclusion in this article were
identiﬁed in review articles published between 2003 and
The literature was also searched using Google
Scholar for 2014 to 2017 to identify additional studies. The
search terms included oral hygiene, oral care, nursing home,
long-term care, pneumonia, and prevention. Two additional
studies pertinent to this article were identiﬁed.
Department of Medicine, Division of Infectious Diseases, School of
Medicine and Biomedical Sciences, State University of New York at
Buffalo, Buffalo, New York.
Address correspondence to Joseph M. Mylotte, 3613 Galway Lane,
Ormond Beach, FL 32174. E-mail: firstname.lastname@example.org
See related editorial by Carol W. Bassim.
JAGS 0:1–5, 2017
© 2017, Copyright the Authors
Journal compilation © 2017, The American Geriatrics Society 0002-8614/18/$15.00
CLINICAL MANAGEMENT OF THE
pneumonia. J Am Geriatr Soc 66:590–594, 2018.
JAGS 66:590–594, 2018
2017, Copyright the Author
2017, The American Geriatrics Society 0002-8614/17/$15.00