Oral Care Reduces Pneumonia in Older Patients in
Nursing Homes
Takeyoshi Yoneyama, DDS, PhD, Mitsuyoshi Yoshida, DDS, PhD, Takashi Ohrui, MD, PhD,
Hideki Mukaiyama, DDS, Hiroshi Okamoto, DDS, PhD, Kanji Hoshiba, DDS, PhD,
Shinichi Ihara, DDS, Shozo Yanagisawa, DDS, Shiro Ariumi, DDS, Tomonori Morita, DDS,
Yasuro Mizuno, DDS, Takayuki Ohsawa, DDS, PhD, Yasumasa Akagawa, DDS, PhD,
Kenji Hashimoto, DDS, MD, PhD, Hidetada Sasaki, MD, PhD, and
Members of the Oral Care Working Group
OBJECTIVES: Aspiration of oral secretions and their bac-
teria is increasingly being recognized as an important fac-
tor in pneumonia. We investigated whether oral care low-
ers the frequency of pneumonia in institutionalized older
people.
DESIGN: Survey.
SETTING: Eleven nursing homes in Japan.
PARTICIPANTS: Four hundred seventeen patients ran-
domly assigned to an oral care group or a no oral care group.
INTERVENTION: Nurses or caregivers cleaned the pa-
tients teeth by toothbrush after each meal. Swabbing with
povidone iodine was additionally used in some cases. Den-
tists or dental hygienists provided professional care once a
week.
MEASUREMENTS: Pneumonia, febrile days, death from
pneumonia, activities of daily living, and cognitive functions.
RESULTS: During follow-up, pneumonia, febrile days, and
death from pneumonia decreased significantly in patients
with oral care. Oral care was beneficial in edentate and den-
tate patients. Activities of daily living and cognitive functions
showed a tendency to improve with oral care.
CONCLUSION: We suggest that oral care may be useful
in preventing pneumonia in older patients in nursing homes.
J Am Geriatr Soc 50:430433, 2002.
Key words: silent aspiration; aspiration pneumonia; oral
health; activities of daily living; cognitive function
From the Department of Geriatric and Respiratory Medicine, Tohoku Uni-
versity School of Medicine, Sendai, Japan.
This study was supported by Funds for Comprehensive Research on Aging
and Health from 1999 to 2000 of the Japan Welfare Ministry.
Address correspondence to Hidetada Sasaki, MD, PhD, Professor and
Chairman, Department of Geriatric and Respiratory Medicine, Tohoku
University School of Medicine, 11 Seiryo-machi, Aoba-ku, Sendai 980
8574 Japan. E-mail: dept@geriat.med.tohoku.ac.jp
JAGS 50:430433, 2002
2002 by the American Geriatrics Society
P neumonia is not only a common infection in older peo-
ple, it is also the most common cause of death from noso-
comial infection in this population.1 Bacterial pneumonia is
thought to be due to organisms that inhabit the oropharynx,
and aspiration of oropharyngeal contents has been suggested
as the mechanism by which these bacteria reach the lower
respiratory tract.2 Many older patients in nursing homes
have poor oral health because of the difficulty of access to
professional dental care and insufficient personal oral hy-
giene care.3 It is recognized that community-acquired
pneumonia and lung abscesses can be the result of infection
by anaerobic bacteria, and dental plaque would seem to be a
logical source of these bacteria, especially in patients with pe-
riodontal desease.4 However, to our knowledge, whether im-
proving oral hygiene would lower the risk in either of these
setting has not been studied. In the present study, we
treated these patients with oral care to minimize respira-
tory infections, possibly caused by silent aspiration. A pre-
liminary experiment has been reported elsewhere.5
SUBJECTS AND METHODS
The present study was performed with older patients in 11
nursing homes in Japan. Each nursing home has from 50
to 100 beds and serves as a long-term care facility for older
patients who are physically handicapped or suffering from
mental deterioration. Thus, to a large extent, they are de-
pendent on the service of caregivers for activities of daily
living (ADLs). The criterion for patient selection was that
physical symptoms and cognitive impairment must have
been stable for the preceding 3 months. During this 3-month
period no patient had acute disorders (e.g., severe infection,
heart failure, or stroke requiring special treatment and inten-
sive care). Chronic diseases suffered by the patients included
previous stroke, hypertension, arrhythmia, previous myo-
cardial infection, diabetes mellitus, and inactive gastric ul-
cer. Mental function varied from slight cognitive impair-
ment to dementia. A few patients in each nursing home could
not participate in the study because they could not give in-
0002-8614/02/$15.00
JAGS MARCH 2002VOL. 50, NO. 3
formed consent. No patient had any chronic pulmonary dis-
ease such as chronic obstructive pulmonary disease, bronchial
asthma, or pulmonary fibrosis. The patients fed themselves
or needed help in eating; no patient had feeding tubes. The
patients were randomly selected from the same floor and
nursing team in each nursing home. Randomization was
made from a random-numbers table, and the list was held
independently of the investigators. No dentist had been in
charge of the institution before the study. Four hundred
seventeen patients were randomly assigned to an oral care
group or a no oral care group in September 1996 and were
investigated for 2 years. Criteria for diagnosis of pneumo-
nia were a new pulmonary infiltrate seen on a chest radio-
graph and one of the following features: cough, tem-
perature greater than 37.8C, or subjective dyspnea. Two
radiologists who were not involved in the studies made the di-
agnosis of pneumonia. However, 51 patients were excluded
from the analysis because they died from causes other than
pneumonia during follow-up. Of the remaining 366 pa-
tients, 184 (mean age  standard deviation (SD) 82.0 
7.8, 148 women and 36 men) had received oral care at
study entry; 182 (mean age 82.1  7.5, 145 women and
37 men) had not received oral care (Table 1).
Before the study, a physical examination and chest ra-
diograph were performed. During follow-up, nurses or
caregivers cleaned the patients teeth with a toothbrush for
approximately 5 minutes after each meal. The brushing
was performed as usual daily toothbrushing without den-
tifrice, including brushing palatal and mandibular mucosa
and tongue dorsum. If the toothbrush was not efficient,
the oropharynx was scrubbed with an applicator with a
minimum amount of povidone iodine (1%) in some cases,
and rinsing was not needed. In the nonoral care group,
several patients performed toothbrushing by themselves
once a day or irregularly but none of them requested oral
care from caregivers. One hundred sixty-three patients
used dentures. In both groups, dentures were cleaned with
a denture brush every day and with denture cleanser once
a week. Dentists or dental hygienists administered profes-
sional care such as plaque and calculus control as neces-
sary once a week for the oral care group. Plaque score was
measured in dentate patients following the Debris Index
reported by Greene and Vermillion6 (0  no debris and
stain present, 1  soft debris covering not more than one-
third of the tooth surface, 2  soft debris covering more
than one-third but not more than two-thirds of the exposed
tooth surface, 3  soft debris covering more than two-
thirds of the exposed tooth surface). Both groups were
treated with usual nursing management of changing sheets
Table 1. Comparisons Between Oral Care and No Oral Care Groups
Number
of Age, Years, ADLs at Baseline, MMSE at Baseline,
Group Patients mean  SD F/M mean  SD
Oral care 184 82.0  7.8 148/36 16.3  6.5
No oral care 182 82.1  7.5 145/37 16.2  6.7
*P  .05 and **P  .01 show significant differences between groups with oral care and no oral care.
SD  standard deviation; F/M  female/ male; ADLs  activities of daily living; MMSE  Mini-Mental State Examination.
ORAL CARE AND PNEUMONIA 431
and gowns once a week, sponge bath once a week, and
changing diapers as required. Cognitive impairment was
evaluated with Japanese versions of the Mini-Mental State
Examination (MMSE).7 Trained neuropsychologists mea-
sured MMSE every 6 months. ADLs were evaluated using
the modified Barthel Index.8 Both MMSE and ADL have a
30-point scale for healthy older people, with a score of 0
indicating complete loss of cognition and dependence. We
took axillary temperatures two times a day; a febrile day
was defined as the axillary temperature rising above 37.8C
at either of the two daily measurements. Patients who had
febrile days for more than 7 cumulative days during 2 years
were assumed to be patients with fever. The Tohoku Uni-
versity Ethics Committee granted ethical approval, and in-
formed consent was obtained from the patients or their
families.
All comparisons were made between the oral care and
nonoral care groups or between dentate and edentate pa-
tients using two-way analysis of variance. Statistical signif-
icance was accepted as P  .05. All data are expressed as
mean  SD.
RESULTS
During follow-up, there were 54 (29%) patients with fe-
brile days in the nonoral care group and 27 (15%) in the
oral care group. The relative risk (RR) for patients who
did not receive oral care compared with those receiving
oral care was 2.45 (95% confidence interval (CI)  1.77
3.40, P  .01). New pneumonia was diagnosed in 34 (19%)
of the 182 patients who did not receive oral care and 21
(11%) of the 184 patients who received oral care. The RR
for patients who did not receive oral care compared with
those receiving oral care was 1.67 (95% CI  1.012.75,
P  .05). There were 130 patients who could feed them-
selves in the oral care group and 116 in the nonoral care
group and 54 patients who need help eating in the oral
care group and 66 in the nonoral care group. Frequency
of pneumonia in patients feeding themselves and those
needing help eating was 9% and 17% in the oral care group
and 13% and 29% in the nonoral care group, respectively.
The RR of pneumonia for patients who needed help eating
compared with patients who could feed themselves was
2.72 (95% CI  1.275.82, P  .01) in the nonoral care
group but was not significant in the oral care group. Of pa-
tients who suffered from pneumonia, 30 (16%) in the non
oral care group died and 14 (7%) in the oral care group
died because of pneumonia. The RR for death of patients
due to pneumonia who did not receive oral care compared
Number of Number of Number of
Patients Patients with Patients
mean  SD with Fever (%) Pneumonia (%) Dying (%)
13.6  6.9 27** (15) 21* (11) 14** (7)
13.9  6.9 54 (29) 34 (19) 30 (16)
432 YONEYAMA ET AL. MARCH 2002VOL. 50, NO. 3 JAGS

Table 2. Effects of Oral Care on Activities of Daily Living (ADLs) and Mini-Mental State Examination (MMSE)

Changes of ADL or MMSE Every 6 Months

6th Month 12th Month 18th Month 24th Month

Index Group Number of Patients Baseline Scores mean  standard deviation

ADL Oral care 170 16.9  6.3 0.4  2.9 1.4  3.7 1.4  3.4 2.1  4.0
No oral care 152 16.9  6.7 0.4  2.6 1.5  4.0 2.2  3.7 2.3  3.7
MMSE Oral care 170 14.3  6.9 0.3  4.2 0.7  4.9 1.3  6.4 1.5  4.9*
No oral care 152 15.0  8.4 0.4  3.7 1.1  4.8 2.0  5.8 3.0  5.9
*P  .05 shows a significant difference between groups with oral care and no oral care.
ADL  activities of daily living; MMSE  Mini-Mental State Examination.

with those receiving oral care was 2.40 (95% CI  1.54
3.74, P  .01) (Table 1).
Mean changes from baseline in ADL and MMSE scores
are shown in Table 2, excluding patients who died from
pneumonia. ADL and MMSE scores showed a tendency to
improve with oral care, but only MMSE at the 24th month
was significant (P  .05).
Comparisons were made between groups with dentate
and edentate patients. Age (P  .01) and MMSE at base-
line (P  .01) showed significant differences (Table 3).
However, a comparison between age-matched dentate pa-
tients with edentate patients showed no significance base-
line MMSE difference. The RR of mortality in the non
oral care group compared with those in the oral care group
was 3.20 (95% CI  1.347.64, P  .05) in dentate pa-
tients. Fewer edentate patients in the oral care group had
febrile days or pneumonia or died from pneumonia, similar
to the rates of dentate patients, although most of the differ-
ences between the oral care group and the nonoral care
group were not significant, probably because of the small
number of edentate subjects (Table 4). Debris Indices were
2.6  0.8 in the oral care group and 2.5  0.9 in the non
oral care group at study entry and 2.3  0.8 in the oral
care group and 2.5  0.8 in the nonoral care group at the
end of the study. When each patient was categorized into
an improved or deteriorated group, oral care significantly
reduced the Debris Index in contrast to nonoral care
(2.81, 95% CI  1.395.69, P  .01).
DISCUSSION
We have shown that patients receiving oral care had fewer
febrile days than did patients not receiving oral care. We
also found that the risk of pneumonia in patients in a long-
term care facility followed up for 2 years was significantly
reduced in patients receiving oral care. The study popula-
tion was very old, and some of the subjects could not per-
form basic ADLs, such as eating without help. Frequency
of pneumonia in patients who needed help eating was less
than that in patients who could feed themselves. The large
majority had neglected their oral health care for a long
time. Thus, the plaque score was high, periodontal disease
and caries were frequent, and dentures, when present, were
in poor condition.9 Oral status was similar to that reported
in a study on institutionalized older people in various coun-
tries.10 The present patients suffered from chronic diseases
and needed long-term care facilities. Although febrile days
may be caused by many conditions, such as small pulmo-
nary emboli and common colds, the present study suggested
that silent aspiration might be an important risk factor for
pneumonia in these patients.11
Pneumonia as the old mans friend suggests a high
prevalence of pneumonia in older people that results in
high mortality.12 In the present institutionalized patients,
80% died after contracting pneumonia (Table 1), but in
patients receiving oral care, the mortality due to pneumo-
nia was about half of that in patients not receiving oral care.
A comparison of mortality after pneumonia suggests that
oral care was much more effective in decreasing mortality
than were medical treatments for pneumonia.
Oral health can dramatically affected the quality of a
persons life, affecting such things as chewing, swallowing,
speaking, facial aesthetics, and social interation.13 MMSE
at the 24th month in patients receiving oral care was sig-
nificantly different from that in patients not receiving oral
care, but we did not observe an overall improvement in
ADL and MMSE scores due to oral care. We administered
the MMSE to patients who were alive for 2 years irrespec-
tive of pneumonia. Thus, patients suffering from pneumo-
nia might have ADL and MMSE degradation. Age-matched
baseline MMSE was also not significantly different between

Table 3. Physical Characteristics in Dentate and Edentate Patients

Patients Number of Patients Age, Years, mean  SD F/M ADLs at Baseline, mean  SD MMSE at Baseline, mean  SD

Dentate 208 79.6  7.8* 162/46 16.9  6.6 15.0  9.2*

Edentate 158 84.6  7.3 131/27 15.9  6.7 12.5  8.5
*P  .01 shows a significant difference between dentate and edentate groups.
SD  standard deviation; F/M  female/male; ADLs  activities of daily living; MMSE  Mini-Mental State Examination.
JAGS MARCH 2002VOL. 50, NO. 3 ORAL CARE AND PNEUMONIA 433

Table 4. Comparisons Between Oral Care and No Oral Care Groups in Dentate and Edentate Patients

Number ADLs at MMSE at Number of Number of Number of

of Age, Years, Baseline, Baseline, Patients with Patients with Patients
Patients Group Patients mean  SD F/M mean  SD mean  SD Fever (%) Pneumonia (%) Dying (%)

Dentate Oral care 109 79.9  7.9 82/27 17.1  6.3 14.8  8.5 13** (11) 12** (9) 8* (6)
No oral care 99 79.3  7.6 80/19 16.7  6.8 15.3  9.9 26 (26) 19 (21) 20 (20)
Edentate Oral care 75 84.3  7.4 63/12 15.8  6.5 12.7  7.8 14* (18) 9 (9) 6 (7)
No oral care 83 84.9  7.1 68/15 16.0  6.9 12.4  9.2 28 (34) 15 (20) 10 (13)
*P  .05 and **P  .01 show significant differences between groups with oral care and no oral care.
SD  standard deviation; F/M  female/male; ADLs  activities of daily living; MMSE  Mini-Mental State Examination.

dentate and edentate patients. To be eligible for inclusion in
the pharmacological trial, dementia patients were required
to have a MMSE score between 10 and 26 and either be
fully ambulatory or able to walk with an assisting device. 14
MMSE score was approximately 13 in the present group,
which may not be sufficient to draw conclusions about oral
care. Therefore, ADL and MMSE scores of more-active pa-
tients may improve with oral care, or a longer-term period
of care may be needed to improve them.
A national survey of oral health in U.S. adults reported
that more than 41% of Americans aged 65 and older were
totally edentate.13 Older edentate persons are supposed to
have a lower risk of developing serious dentally derived sys-
temic diseases than dentate patients, but the present results
suggest that even in older edentate patients, fever, pneumo-
nia, and death from pneumonia were observed as often as
in dentate patients, and oral care in edentate patients pro-
duced benefits similar to those in dentate patients.
We conclude that removal of latent oral infections and
potential problems might be a way to reduce the incidence
of lower respiratory tract infection. In light of the central
importance of oral health to an older patients overall well-
being, it is essential that all health providers support and
advocate the expansion of oral health benefits for older
adults, dentate or edentate.
ACKNOWLEDGMENTS
We are very grateful to the Department of Removable Pros-
thodontics, Faculty of Dentistry Hiroshima University; the
Department of Dental and Oral and Maxillofacial Surgery,
Hamamatsu University School of Medicine; the Department
of Periodontology, Ohu University School of Dentistry; Sen-
dai Dental Association; Futyu City Dental Association; Yono
City Dental Association; and the Amagasaki City Dental As-
sociation for their generous assistance with this study. We are
also thankful to ELVA Co. Ltd and Inoue Attachment Inc.
for their help.
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