Dr. Elahe Ghasemzade Hosseini

ORAL MANAGEMENTS FOR HOSPITALIZED

PATIENTS

تصویر بیمار بستری

prevention& Management

l

prevention

l

Nosocomial pneumonia is the

second most common

infection (after infections of

the urinary tract ) in long-term

care institutions.

approximately 10% to 15% of

all hospital-acquired

infections, and 20% to 50% of

affected patients will die

because of the infection

mortality rates institutionalized

patients as high as 41%.

VAP is a relatively common nosocomial

infection in critically ill patients, with a

reported prevalence ranging between

6%- 52%

Medically

compromised

patients in ICUs or

in nursing homes,

especially if they

are dentate, are

at risk of

pneumonia, which

can be prevented

by professional

oral hygiene

interventions and

frequent health

care.

Aspiration Pneumonia

occurs in hospitalized

patients and increases

morbidity, mortality, and

cost of care.

Micro-aspiration of

pharyngeal

secretions may

also occur around

an imperfect seal

of the cuff of the

endotracheal tube

in a ventilated

patient !

Two routes oral microorganisms to the

lower respiratory tract:

1- Hematogenous spread dental treatment

respiratory disease In healthy

patients, the distal airway and

lung parenchyma are sterile,

despite the heavy bacterial

load (106 aerobic bacteria and

107 anaerobic bacteria per

millilitre) found in the upper

airway. An infection occurs

when the host’s defences are

compromised, the pathogen is

particularly virulent or the

inoculum is overwhelming

2- Aspiration

The micro-organisms may enter the lung by

inhalation, but the most common route of

infection is aspiration of what pneumologists

have long referred to as oropharyngeal

secretions !

Respiratory infections

the agent has to reach the

lower respiratory

tract

the host’s defenses must

be compromised

the pathogen must be

particularly virulent

Overwhelming

inoculum

1.Periodontal Disease or poor

oral hygiene might result in a

higher concentration of oral

pathogens in the saliva

2.Dental Plaque could harbor

colonies of pulmonary pathogens

and promote their growth.

3.The proximity of tongue to the

lung debris on the tongue is more likely

to be aspirated into the lungs

compared to debris on the teeth.

Mechanisms of infection related

to aspiration:

In a study 40%

intensive care

patients, dental

plaque was colonized

by aerobic respiratory

pathogens.

Within 48 hours of admission

to the intensive care unit

(ICU), oral flora of critically ill

patients undergoes a change

to predominantly gram-

negative flora that includes

more virulent organisms.

Anaerobic and Gram negative

species of plaque > invasion +

bacterial Toxins > immune

system overreaction(neutrophils

degranulation,proteolytic

enzymes, …) > connective

tissue alteration and

periodontal disease.

Periodontal diseases result in

a higher concentration of

Gram-negative and anaerobic

oral pathogens in saliva as well

as in patients with neglected

oral hygiene.

The pathogens would then

be aspirated into the lung,

overwhelming the immune

defenses.

• Actinobacillus

actinomycetemcomitans

• Fusobacterium nucleatum

• Pseudomonas aeruginosa

• Bacteroides gingivalis

• Streptococcus intermedius

• Staphylococcus aureus

• Streptococcus pneumonia

• gram negative rods

Bacterial coinfection in the respiratory tract involving S. aureus, S. pneumoniae, and H.

influenza commonly occurs. S. aureus with the influenza virus have a high fatality rate specially in the elderly.

1) Alteration of receptors on the

surface of the mucosal cells to promote adhesion of pulmonary pathogens!!!!! 2) Degradation of the salivary pellicle coating pulmonary pathogens

3) Degradation of Fibronectin 4) cytokines and other molecules

PATHOPHYSIOLOGY

1. presence of a large variety

of cytokines and other

biologically active

molecules.

2. peripheral mononuclear

cells may alter the

respiratory epithelium and

promote colonization by

respiratory pathogens

Effects of cytokines and other

molecules:

3.Salivary proteolytic enzymes (mannosidase, fucosidase,

hexosaminidase,sialidase)

modify respiratory tract mucosal surfaces and promote adhesion and colonization by respiratory

pathogens. source of these salivary enzymes(originated

from the gingival

sulcus/pocket) has been

attributed to both the oral

microbiota and polymorphonuclear leukocytes.

The worse the oral hygiene & the poorer the

oral condition, the higher the enzymatic activity

& greater mucosal changes will be , resulting in

respiratory pathogens adhesion.

Hydrolytic enzymes from

periodontopathic bacteria

(like P.gingivalis) may destroy the

salivary film that protects against

pathogenic bacteria.

108 microorganisms have been detected per

milliliter of sliva, mostly derived from oral

mucosal surfaces such as the tongue.

4.Immunoglobulins and

Antimicrobial Enzymes

(lactoferrin, lysozyme,

lactoperoxidase

statherin,histatins) is of

fundamental importance in

maintaining health & regulating

microbiome.

108 microorganisms have been detected per

milliliter of saliva, mostly derived from oral

mucosal surfaces such as the tongue.

5. The cryptic virus receptors in

the oral pharynx mucous

membranes are known to be

covered by salivary

components such as sialic acid,

and these receptors may be

exposed by microbial

enzymatic activities(e.g.

Neuroaminidase)

It is also possible that a lower

prevalence of infection by cold

viruses occurred in the POHC

group.

Maintaining good oral hygiene plays an important role in preventing respiratory infection as a part of the nursing regimen

of elderly people, even for COVID-19

Generation of proteases by infected bacteria in the upper

airway play key role in activation of the hemagglutin (HA) to

HA1 and HA2 and in the virus infection. increase in oral bacteria

due to poor oral hygiene increase the risk of infection by

multiplication of the influenza virus. Professional oral care

reduced the level of oral bacteria and enzymatic activity ,and

that this lowered the risk of infection with the influenza virus.

Maintaining good oral hygiene plays an important role in preventing respiratory infection as a part of the nursing regimen

of elderly people, even for COVID-19

1.Periodontal Disease or poor

oral hygiene might result in a

higher concentration of oral

pathogens in the saliva

2.Dental Plaque could harbor

colonies of pulmonary pathogens

and promote their growth.

3.The proximity of tongue to the

lung debris on the tongue is more likely

to be aspirated into the lungs

compared to debris on the teeth.

Mechanisms of infection related

to aspiration:

The tongue has a rough and fissured surface which is an effective

colonization surface for formation of a microbial biofilm.

This is more important in hospitalized adults who have impaired

physical and immunological oral defenses (e.g. ineffective oral toilet,

decreased oral clearance due to low salivary flow from

polypharmacy).

90% of the dependent elderly harbored these organisms on the

tongue rather than plaque.

There are correlations between the tongue colonization of

H. influenzae and P. aeruginosa at baseline and their presence in the

sputum at time of pneumonia diagnosis.

Tongue colonization by respiratory pathogens could serve as a

good proxy for the various risk factors and be used as a convenient

and accessible indicator for the risk of pneumonia development from

oral sources , because of The positive links between tongue

colonization with plaque colonization & naso-gastric feeding tube&

tracheostomy.

Three site-specific distinct

patterns were observed on:

-tongue

-hard palate

-dental plaque

suggesting that the location

of colonization of respiratory

pathogens may significantly

impact pneumonia

occurrence.

Different studies suggested cleaning of tongue

and hard palate separately in particular In

elderly population

The typical coronavirus

structure includes the “spike

protein” in the membrane

envelope, and also other

polyproteins, nucleoproteins,

and membrane proteins, such

as RNA polymerase,

3-chymotrypsin-like protease,

papain-likeprotease, helicase,

glycoprotein, and accessory

proteins.

Structure

The S protein from

coronavirus can bind to the

receptors of the host to

facilitate viral entry into

target cell SO 2019-nCOV

can also bind to the human

angiotensinconverting

enzyme 2 (ACE2) which may

promote human-to-human

transmission .

The population with higher expression of ACE2

might be more susceptible to 2019-nCoV

because of the high affinity between ACE2 and

2019-nCoV S protein

ACE2+ cells are present

throughout the respiratory tract,

as well as the cells

morphologically compatible with

salivary gland duct epithelium in

human mouth. ACE2+ epithelial

cells of salivary gland ducts were

demonstrated to be a early

targets of SARSCoV infection,

and 2019-nCoV is likely to be the

same situation.

• ACE2 receptors are highlyexpressed on the

mucosa of oral cavity and

are present notably in

large amounts in epithelial

cells of the tounge so these findings indicate that

oral cavity is high risk

transmitter of 2019-n CoV

infection and this can be

prevented by oral hygine.

Zhou et al. also proved that 2019-nCoV does not use other coronavirus receptors,

aminopeptidase N, and dipeptidyl peptidase [5].

The study of Xu et al. found that the RBD domain of the 2019-nCoV S-protein supports strong

interaction with human ACE2 molecules. These findings suggest that the ACE2 plays an

important role in cellular entry, thus ACE2-expressing cells may act as target cells and are

susceptible to 2019-nCoV infection [6].

tongue than buccal or gingival tissues

lymphocytes within oral mucosa

lymphocytes and leads to the severe

illness of patients needs more in vitro

and in vivo evidence and validations,

though the proportion of ACE2-positive

lymphocytes is quite small,

Angiotensin-converting enzyme 2 (ACE2) is a enzyme attached to the cell

membrane of cells in the lungs, epithelial linings of oral and nasal mucosa,

arteries, heart, kidney and intestine.

AC2 lowers blood pressure by the degradation of Ang II resulting in the

formation of angiotensin 1–7 (Ang 1–7) [1].

According to the study of Zhao et al., the ACE2 expression in lung is

concentrated in a small population of type II alveolar cells (AT2), that may

cause the relatively low ACE2 expression of lung in bulk-seq RNA datasets

analysis. Even though, the result of Zou et al. indicated that the respiratory

tract should also be considered as a vulnerable target to 2019-nCoV

infection [1].

. According to the site information provided by the TCGA, among the 32

adjacent normal tissues, 13 tissues located in the oral tongue, 2 tissues located

in the base of tongue, 3 tissues located in the floor of mouse, and 14 tissues

did not definite the site and were just put into the category of oral cavity. The

mean expression distribution of different sites was shown in previous figure.

When we combined the base of tongue, floor of mouth and oral cavity as

other sites, and compared them with oral tongue, we found the obvious

tendency that the mean expression of ACE2 was higher in oral tongue (13

tissues) than others (19 tissues) [

Management

l

Elderly Individuals

present alterations in the

mucosa, increasing their

susceptibility to oropharyngeal

colonization and diminishing

their ability to defend against

respiratory pathogens that

way age has been considered

a risk factor for nosocomial

pneumonia and respiratory

infections.

It is essential to provide care that focuses on

cleansing of the oral cavity in a regimen

suitable for the elderly. There is the

relationship between an individual’s length

of hospital stay and their salivary flow.

Increased Bacterial

Colonization

Presence of the orotracheal

tube

Impossibility of self-care

Consequent formation of the biofilm & dental

plaque

Inadequate immunological

response

Low saliva flow

Decreased mastication &

tongue movement

Plaque colonization may be

exacerbated in the absence

of adequate oral hygiene

care.

Prolonged mouth opening

Drying of the oral cavity

Decrease in the buffering

and cleansing effects of

saliva

.

Salivary Secretion has a significant role in maintaining oral health and that its

suppression or diminution leads to difficulty in swallowing and increases the risk of

developing opportunistic infections by aspiration of these pathogens ,so it is

possible to aggravate the patient`s condition and may perpetuate new

infection by means of inflammatory and immunologic intermediary factors.

milking of salivary glands is an efficient manoeuvre for balancing its

secretion.

Xerostomia:

Oral hygiene care (OHC)

begun very early in the ICU stay /In each quadrant; every

tooth was brushed for 5 strokes

on lingual, buccal, and biting

surfaces with a soft toothbrush

3times or more daily at least 1_4 minutes

Bend the head forward and

downward while brushing to

reduce the risk of swallowing the removed microorganisms

Wash the mouth with water after

using Inhalation spray

Denture

stomatitis: Candida albicans is

associated with denture

stomatitis, an inflammation

of the palatal mucosa

covered by denture.

An

gu

lar

Ch

eilitis

Sy

ste

mic

Missed diagnosis of

HSV

aphthous ulcer

SSC

Eritema multiform

aphthous ulcer

Ap

hth

ou

s u

lce

r

SCC

Eritema

Multiform

They are continually

placed in environments

where they are

exposed to pathogens

(respiratory pathogens

readily adhere to the

mucous membranes in

the oral cavity) They must gargle Povidone-

iodine even at very dilute

concentration or

chlorhexidine mouthwash

0.1 or 0.2 or 0.12 percent

between medical procedur.

TASTE DISORDERS

The mucociliary clearance

of the airways and the

cough reflex are weaker in

elderly persons with

decreased ADL , so

aspiration of small amounts

of secretion from the oral

cavity tend to increase

during sleep and among

patients

cost savings

1 .

Effect of oral health education and

provision among the high-risk people:

Effect of oral health education and

provision among the high-risk people:

improving the quality of life

2 .

Effect of oral health education and

provision among the high-risk people:

decreasing hospital

admissions

3 .

Effect of oral health education and

provision among the high-risk people:

4 . reducing incidence

of nosocomial

40 %

Thanks For Your Attention