Your new patient comes in with her caregiver in a wheelchair. She is 83 years old and accompanied by her daughter who is carrying a box of Kleenex. The patient starts coughing and the daughter tells you that she has a history of pneumonia and hands her a tissue. You nod and continue with your examination after reviewing her medical history.
What is Pneumonia?
Pneumonia is a significant threat to the older adult population. It also accounts for nearly 17,000 deaths per year among individuals aged 60 and older [1]. Aspiration pneumonia is often caused by inhaling saliva, food and liquid, oral biofilm and debris from the mouth, vomit, and even small foreign objects.
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Who is more likely to get aspiration pneumonia?
This condition is more common among people who:
- Have had general anesthesia or dental procedures
- Have trouble coughing or trouble swallowing (dysphagia)
- Are older (65 and over), especially those living in nursing homes or care facilities
- Have weak immune systems due to some illness or underdeveloped immune system
How Common Is Aspiration Pneumonia?
Aspiration of food or drink is relatively common as we often hear people say food “going down the wrong pipe”, meaning food and drinks go towards the lungs instead of the stomach. When this happens, you probably cough until you feel better. When this happens to someone who can’t cough, especially to older adults with diminished function, aspiration pneumonia may occur [2].
Symptoms and Causes
What causes aspiration pneumonia?
Aspiration pneumonia can be caused by inhaling foreign materials into the lungs. The materials may be [3]:
- Bacteria from saliva and secretions from the mouth and nose
- Periodontal bacteria Anaerobic Gram-negative bacterial
- Stomach contents such as digestive juices or vomit
- Food or beverage
- Small foreign objects
What are the symptoms of aspiration pneumonia?
- Shortness of breath or wheezing
- Coughing up blood or pus
- Chest pain
- Bad breath
- Extreme tiredness
Symptoms can start very quickly, even one to two hours after inhaling foreign materials. It may day a day or two for pneumonia to develop.
How is aspiration pneumonia diagnosed?
Generally, the provider will take a complete medical history, perform a physical examination and ask about the current signs and symptoms. The tricky thing about aspiration pneumonia is that often times, no one will have seen the person breathe in an object or food or saliva (or biofilm/calculus).
In addition to the physical exam, the physician will order tests such as:
- Chest x-rays and/or a computed tomography (CT) scan
- Blood test, including complete blood count.
- Sputum culture
- Bronchoscopy
- Swallowing studies
Management and Treatment
How is aspiration pneumonia treated?
Aspiration pneumonia can be treated with antibiotics. Additional treatment may include oxygen therapy or in life-threatening cases, mechanical ventilation.
Preventing further aspiration is an important part of treatment since every episode of aspiration can lead to inflammation or infections.
How do we prevent aspiration pneumonia?
At Home:
Mechanical hygiene measures such as tooth brushing and flossing can reduce the incidences of pneumonia. We can recommend that patient brush their teeth after every meal, clean their dentures once a day and have a professional oral health checkup frequently to prevent and reduce the incidences of aspiration pneumonia [4].
The addition of oral rinses may not provide additional benefits [5]. If the patient is prone to choking, having oral rinses and additional liquid inside the patient’s mouth may not be beneficial.
At the Dental Office:
The patient’s chair position should be adjusted (at no less than 45 degrees) to prevent unnecessary items from going down the patient’s throat.
There should be thorough suctioning of oropharyngeal contents throughout the appointment with a high vacuum suction and saliva ejector.
The patient’s oxygen saturation level should also be monitored using a pulse oximeter and immediate steps should be taken to clear the airway and deliver oxygen if hypoxia is noted.
As the population continues to age, it is crucial for dentists to consider potential age-related medical conditions, overall health, and the patient’s functionality, in order to provide the most effective treatment for their older adult patients.
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References:
- Gupte T, Knack A, Cramer JD. Mortality from Aspiration Pneumonia: Incidence, Trends, and Risk Factors. Dysphagia. 2022 Dec;37(6):1493-1500. doi: 10.1007/s00455-022-10412-w. Epub 2022 Jan 31. PMID: 35099619.
- Pace, C.C., McCullough, G.H. The Association Between Oral Microorgansims and Aspiration Pneumonia in the Institutionalized Elderly: Review and Recommendations. Dysphagia 25, 307–322 (2010). https://doi.org/10.1007/s00455-010-9298-9
- Sanivarapu RR, Gibson J. Aspiration Pneumonia. [Updated 2023 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470459/
- Yi Mohammadi JJ, Franks K, Hines S. Effectiveness of professional oral health care intervention on the oral health of residents with dementia in residential aged care facilities: a systematic review protocol. JBI Database System Rev Implement Rep. 2015 Oct;13(10):110-22. doi: 10.11124/jbisrir-2015-2330. PMID: 26571287.
- van der Maarel-Wierink CD, Vanobbergen JN, Bronkhorst EM, Schols JM, de Baat C. Oral health care and aspiration pneumonia in frail older people: a systematic literature review. Gerodontology. 2013 Mar;30(1):3-9. doi: 10.1111/j.1741-2358.2012.00637.x. Epub 2012 Mar 6. PMID: 22390255.
