Periodontal disease and respiratory disease: how many studies will be enough to confirm this association? How do we interpret the research studies to determine the clinical significance of the findings reported?

In recent years, the literature has been replete with studies and continuing education articles addressing the connection between periodontal disease and systemic diseases. Of interest in this issue is the link between periodontal disease and respiratory disease.

Our scientific literature provides the biologic basis for the connection between periodontal disease and respiratory disease, particularly with respect to pneumonia. Studies have found that aspiration of food, bacteria and saliva from the oral cavity can lead to inflammation of the lungs and bronchial tubes. Lack of clearance by the immune system leads to local infection that causes the symptoms of pneumonia. Community-acquired, hospital-acquired and ventilator-associated pneumonia are significant concerns in hospital and long-term care facilities. Nursing homes have high rates of risk factors predisposing to any of the above-mentioned pneumonias. These include altered or reduced consciousness, dementia, stroke, gastric-tube feeding, mechanical ventilation, dysphagia, poor functional status and age. These factors are compounded by a lack of specifically designated staff to perform oral care daily and nonadherence to oral care for nursing home residents.

While we understand the biologic mechanisms linking periodontal disease and respiratory disease, many questions still arise about this relationship. For example, how many studies will be enough to confirm this association? How do we interpret the research studies to determine the clinical significance of the findings reported? Can we draw the same conclusions about other chronic respiratory diseases such as COPD and asthma? In addition, knowing the challenges that must be faced when providing oral health care in these settings, how do these findings influence best practices in medicine, dentistry and dental hygiene? Resolving these questions will assist health care providers in implementing collaborative care to prevent respiratory disease from occurring in institutional settings, and in treating it more effectively to avoid mortality.

In contemplating this editorial, I am reminded of an all too recent experience. My father has a chronic respiratory condition that renders him susceptible to upper respiratory infections. Unfortunately, he developed a cold that rapidly progressed to bilateral pneumonia infiltrating all lobes of the lungs. He had been hospitalized for the pneumonia and treated with antibiotics, but as his condition progressed, he was rushed into the ICU and a ventilator was placed. It was doubtful that he would survive the night, let alone the weekend. My sister, who happens to be a physician, worked closely with the medical team of doctors, nurses and respiratory therapist to monitor his condition and problem-solve, creating the balance between maintaining heart function and treating this massive infection.

During that first night of respiratory and cardiac distress, my husband and I stayed with my father so that the rest of the family could try to get some rest. We developed a schedule of shifts with family members so my dad would not be alone. During the quiet time of late evening, I had an opportunity to discuss oral health care concerns with the ICU nurses and a doctor. I expressed interest in how the ventilator and my father's mouth would be cleaned, knowing that biofilm from the mouth would be present on the vent. In addition, I noted concern about the development of a candidal infection, as a fungal infection could compound the situation. The response I received was that my father's condition was too tenuous to worry about mouth care. If he developed any oral conditions, they could be addressed at a later time. The concept of prevention of further infection was lost on them.

When my sister returned from her respite, I discussed my concerns with her and the need to provide regular oral care to avoid further infection. She listened carefully and the two of us addressed this issue again with the ICU nursing team. We were provided a suction device and toothettes to use. I obtained an antiseptic mouthrinse and we provided oral care as much as possible over the weekend. My concerns were soon realized when I noted the presence of fungal disease by the third day. A topical antifungal agent was prescribed, but again, there appeared to be little concern for the oral infection as the pneumonia continued unabated.

The good news is that my father was strong enough to withstand the respiratory and oral infections. It took several weeks for both infections to clear his system, and several weeks of recovery in a rehabilitation center following hospitalization. However, this encounter made me realize how we do not have a formal system in place that helps medical teams recognize and treat oral disease during hospitalization or long-term care.

Recently, I attended a meeting related to dental products sponsored by Discus Dental, Inc. One of their products is a Caries Control Kit. It made me think about the need to create a "Respiratory/Oral Care Kit" that included an antiseptic mouthrinse or chlorhexidine gluconate, a mouthspray, and tongue cleaner as a basic prototype that could be used to treat those in respiratory distress. Cleansing the mouth and tongue several times daily would lower the bacterial and fungal counts, perhaps helping to prevent and/or control infection. Keeping the mouth moist would also help reduce discomfort for the patient. A product company or industrious hygienist looking for a new twist on managing oral disease might want to test the usefulness of such a kit.

As we explore the relationships between oral health and systemic health, it becomes clear that there are numerous opportunities for medical and oral health professionals to work together to improve health outcomes. Read more about these opportunities in this issue. The challenge for all of us is to both learn from the experts and to become recognized experts ourselves.

JoAnn R. Gurenlian, RDH, PhD, is the owner of Gurenlian & Associates, offering consulting and continuing education programs for health care providers. She has experience in general, periodontic, pediatric, and orthodontic practices, and works part-time in a medical practice. She is an internationally recognized speaker on the topics of oral pathology, oral medicine, diabetes, and women's health. She currently serves as the Vice President of the International Federation of Dental Hygienists, and Chair of the Pharmacy, Podiatry, Optometry, and Dental Professionals (PPOD) Work Group of the National Diabetes Education Program (NDEP).