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To the Editor: Risk factors for pneumonia in older people include impaired cognitive function and limited ability to perform activities of daily living (ADLs). Silent aspiration due to a depressed swallowing reflex, which is mediated via substance P (SP), is another known risk factor.¹ We recently reported that long-term oral care reduced the risk of pneumonia among elderly Japanese nursing home patients.² However, it is not known whether intensive oral care affects these risk factors for pneumonia.

Methods
Forty elderly nursing home patients with dysphagia due to cerebrovascular disease were randomly assigned to either aggressive oral care or to usual treatment. The 20 patients in the intervention group (11 men, 9 women; mean age, 75 years) had their teeth and gingiva cleaned by caregivers with a toothbrush and distilled water after every meal for 1 month. The other 20 patients (10 men, 10 women; mean age, 76 years) performed their own oral care during the same period.

The swallowing reflex was provoked by a bolus of 1 mL of distilled water injected into the pharynx through a nasal catheter, and was quantified as the latency time of the swallowing reflex (LTSR) from the injection to the onset of swallowing.³ The LTSR before breakfast was examined before the study and at 3, 10, and 30 days after the study began. Saliva was collected before LTSR examination and assessed for SP. Individual ADL scores were assessed by a 7-item questionnaire.⁴ Cognitive function was assessed by Mini-Mental State Examination (MMSE).⁵ The salivary SP concentration and ADL and MMSE scores of each participant were obtained at the beginning of the study and at 30 days.

Results
There were no significant baseline differences in LTSR, SP, and ADL and MMSE scores (Table 1). Daily oral care was associated with significant decreases in LTSR at 3, 10, and 30 days compared with the control group (P<.001). Salivary SP and ADL scores were significantly higher in the intervention group than in the control group (SP: odds ratio [OR], 7.1; 95% confidence interval [CI], 1.3-38.7; P = .03; ADL scores: OR, 6.1; 95% CI, 1.5-35.7; P = .03 by the Fisher exact test). There was no significant change in MMSE scores.

View this table: [in this window] [in a new window] Table. Effect of Oral Care on Risk Factors for Pneumonia*

Comment
Our data suggest that oral care may improve the swallowing reflex and the ability to perform ADLs among elderly patients. The elevated SP levels in the oral care group suggest that daily brushing stimulates sensory nerves in the oral cavity by enhancing release of neuropeptides, through afferent or efferent pathways of the swallowing reflex. Oral care may reduce the risk of pneumonia by improving the swallowing reflex and by improving overall functional status.

Akiko Yoshino, MD; Takae Ebihara, MD, PhD; Satoru Ebihara, MD, PhD; Hidetoshi Fuji, DD; Hidetada Sasaki, MD, PhD
Department of Geriatric and Respiratory Medicine
Tohoku University School of Medicine
Sendai, Japan

1. Yamaya M, Yanai M, Ohrui T, Arai H, Sasaki H. Interventions to prevent pneumonia among older adults. J Am Geriatr Soc. 2001;49:85-90. FULL TEXT | WEB OF SCIENCE | PUBMED 2. Yoneyama T, Yoshida M, Matsui T, Sasaki H. Oral care and pneumonia. Lancet. 1999;354:515. WEB OF SCIENCE | PUBMED 3. Iwasaki K, Wang Q, Nakagawa T, Suzuki T, Sasaki H. The traditional Chinese medicine banxia houpo tang improves swallowing reflex. Phytomedicine. 1999;6:103-106. PUBMED 4. Matsubayashi K, Okuniya K, Osaka Y, Fujiwara M, Doi Y. Frailty in elderly Japanese. Lancet. 1999;353:1445. FULL TEXT | WEB OF SCIENCE | PUBMED 5. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state": a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189-198. FULL TEXT | WEB OF SCIENCE | PUBMED

Letters Section Editors: Stephen J. Lurie, MD, PhD, Senior Editor; Jody W. Zylke, MD, Contributing Editor.

JAMA. 2001;286:2235-2236.

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