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Year : 2020  |  Volume : 4  |  Issue : 3  |  Page : 142-147

Association of oral health status with the risk of malnutrition and pneumonia in geriatric patients

1 Oral Medicine Residency Program, Faculty of Dentistry, Universitas Padjajaran, Bandung; Department of Oral Medicine, Faculty of Dentistry, Trisakti University, Jakarta, Indonesia
2 Department of Oral Medicine, Faculty of Dentistry, Universitas Padjajaran, Bandung, Indonesia

Date of Submission23-May-2020
Date of Decision02-Sep-2020
Date of Acceptance16-Sep-2020
Date of Web Publication17-Oct-2020

Correspondence Address:
Firstine Kelsi Hartanto
Department of Oral Medicine, Trisakti University, Kyai Tapa Grogol 260, Jakarta 11440
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/SDJ.SDJ_42_20

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Background: Older persons are at risk of compromised oral conditions, including dental infections, periodontal problems, tooth loss, benign mucosal lesions, xerostomia, oral candidiasis, and oral cancer. Poor oral hygiene has contributed to increase the risk of aspiration pneumonia, as well as malnutrition, in geriatric patients. We described cases of poor oral health status associated with increased risk of malnutrition and pneumonia in geriatric. Case Report: The patients were an 80-year-old female and a 61-year-old male who were referred from the Internal Medicine Department to the Oral Medicine Clinic at the Dr. Hasan Sadikin Hospital, Bandung, for the evaluation and management of oral health problems. Their medical histories revealed that they had low nutritional intake prior to being hospitalized. Clinically, both patients had pale conjunctiva and appeared underweight. Anthropometry measurements of the female patient showed her body weight was 36 kg, height was 150 cm, and upper-arm circumference measurement was 20 cm, whereas the male patient was measured at 43 kg, 174 cm, and 20 cm, respectively. The nutritional status based on percentage upper-arm circumference measurement method or called % Lingkar Lengan Atas of both patients were 66.8%. Intraoral findings showed coated tongues, multiple gangrene radix at all regions, plaque, and calculus seen on most tooth surfaces, and a lack of saliva. A thorax radiography examination found the patients had pneumonia. A diagnosis of community-acquired pneumonia, severe malnutrition, xerostomia, and periodontitis was made for each patient. The management of the patients included administering systemic antibiotics, promoting their nutritional status gradually with adequate intake, and improving their oral health status with an antiseptic mouthwash and the rehabilitation of malfunctioning teeth. Conclusion: Oral health status has a close relationship with the risk of malnutrition and pneumonia in geriatric patients. Therefore, comprehensive management is needed to improve the quality of life of geriatric patients.

Keywords: Geriatric patient, malnutrition, periodontitis, pneumonia, poor oral hygiene, xerostomia

How to cite this article:
Hartanto FK, Dewi TS. Association of oral health status with the risk of malnutrition and pneumonia in geriatric patients. Sci Dent J 2020;4:142-7

How to cite this URL:
Hartanto FK, Dewi TS. Association of oral health status with the risk of malnutrition and pneumonia in geriatric patients. Sci Dent J [serial online] 2020 [cited 2022 Oct 4];4:142-7. Available from: https://www.scidentj.com/text.asp?2020/4/3/142/298444

  Background Top

Malnutrition is a condition in which a person has deficiencies, excesses, or imbalances of energy and or nutrition intake. There are three broad groups of malnutrition conditions: (1) undernutrition, which includes wasting, stunting, and being underweight; (2) micronutrient-related malnutrition, which includes micronutrient deficiencies or excesses; and (3) overweight, obesity and diet-related noncommunicable diseases, such as heart disease, diabetes, and some cancers.[1] Malnutrition condition is often observed in the older adult population. An epidemiological study of malnutrition in elderly people in 12 countries showed its prevalence was 23%. The highest prevalence was observed in rehabilitation settings (50.5%), followed by hospitals (38.7%), nursing homes (13.8%), and communities (5.8%).[2]

There are several factors which may cause malnutrition in geriatric patients, including inadequate food intake, food choices that lead to dietary deficiencies, and diseases that cause increased nutrient requirements, increased nutrient loss, poor nutrient absorption, or a combination of these factors.[3] Malnutrition is related with some adverse health conditions in the elderly, such as increased morbidity and mortality, prolonged hospital stays, functional impairment, poor quality of life, increased infection, electrolyte imbalance, anemia, muscle wasting, and fatigue.[4],[5],[6],[7],[8]

Nutritional screening are varies, depending on a person's nutritional problem, so that the individuals identified can undergo a full nutritional assessment and possible intervention.[9] One's nutritional condition can be measured using the body mass index, anthropometry, biochemical markers, and malnutrition screening tools, such as the Malnutrition Universal Screening Tool and the Mini Nutritional Assessment.[10] Another method for nutritional status screening is upper-arm circumference measurement method or Lingkar Lengan Atas (LILA), which describe the condition of muscular and adipose tissue beneath the skin. The formula of this method is % LILA = (Result of LILA measurement: LILA standard) ×100%. LILA standard is 28.5 cm for female and 29.3 cm for male. The interpretation of % LILA are obesity (>120%), overweight (110%–120%), normal (90%–110%), and underweight (<90%).[11]

Pneumonia is an acute respiratory infection of the lungs in which breathing is painful and oxygen intake is limited that is caused by pus and fluid in the alveoli. Viruses, bacteria, and fungal infections have been identified as causes of pneumonia that can be inhaled into the lungs.[12] Several studies have reported that there is an association between aspiration pneumonia and dental decay, periodontal disease, poor oral hygiene, the need for assistance when eating, and swallowing problems.[13],[14],[15],[16] A case series of malnutrition and pneumonia related with poor oral hygiene condition in geriatric patients and the conditions' management is described.

  Case Reports Top

Case 1

An 80-year-old female patient was referred from the Geriatric subdivision of the Internal Medicine Department in Dr. Hasan Sadikin Hospital, Bandung, for an evaluation of her oral health condition, including xerostomia, pulpitis, and bad oral hygiene. Alloanamnesis (anamnesis with patient's family) found there was a history of loss of consciousness 1 day prior to her admission to the hospital. A history of her present condition revealed that the patient had less nutritional intake than normal, as well as a loss of consciousness, coughing, and sleep disturbance in the 1 month prior to her hospitalization. Anthropometry measurements showed the patient's body weight was 36 kg, height was 150 cm, and upper-arm circumference measurement was 20 cm. % LILA was 66.8%. The examination of the patient's general condition showed her to be febrile with dyspnea, but blood pressure and pulse rate were normal. Her past dental history revealed that no regular dental check-ups had been done. An extraoral examination showed that the conjunctiva was pale, the vermilion was dry and exfoliated, and that the patient was on oxygen [Figure 1]. Intraorally, there were multiple fissures and a moderately thick-coated tongue [Figure 2]. Multiple gangrene radix were observed in the right and left maxillary regions [Figure 3], calculus and plaque were seen mostly at the lingual surface of the anterior teeth [Figure 4], and a lack of salivary pooling was noticed on the floor of the mouth [Figure 5].
Figure 1: Patient appeared underweight and on oxygen aids

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Figure 2: Fissured and coated tongue

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Figure 3: Exfoliative upper vermilion and multiple gangrene radix

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Figure 4: Calculus and plaques seen at the lingual surface of anterior teeth

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Figure 5: Lack of salivary pooled and dry lower vermilion observed

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Laboratory findings showed hemoglobin, hematocrit, erythrocyte, thrombocyte, lymphocyte, and mean corpuscular hemoglobin concentrations were lower than normal, whereas segment neutrophil was slightly higher than normal. A microbiological examination of the patient's sputum showed positivity for fungal hyphae.

Based on the clinical examination, the patient was diagnosed with community-acquired pneumonia, moderate dehydration due to inadequate intake and gastrointestinal loss, severe malnutrition and hypokalemia due to gastrointestinal loss, and thrombocytopenia. Intraorally, the patient had mild dryness of the oral mucosa, a fissured and coated tongue, chronic apical periodontitis due to several gangrene radix, and generalized chronic gingivitis. The intraoral condition of the patient may contribute to her general condition.

Medications given to the patient to treat her pneumonia and improve her general condition included antibiotic azithromycin 500 mg, parenteral ceftriaxone 1 mg, paracetamol 500 mg, acetylcysteine 200 mg as a mucolytic agent, parenteral potassium chloride, and omeprazole. Instruction and education were given to improve and maintain her oral hygiene condition using gauze moistened with chlorhexidine digluconate 0.12% mouthwash three times daily to clean the teeth, oral mucosa, and dorsum of the tongue. Vaseline petroleum jelly to reduce dryness of the lips was also given. She planned to have all the gangrene radix extracted gradually when the general and hematological conditions had improved. The patient was discharged after 5 days, showing improvement of her general condition from the hospital treatment. The same instructions and education, along with medications, were given to continue at home.

Case 2

A 61-year-old male patient was referred from the Internal Medicine Department at Dr. Hasan Sadikin Hospital, Bandung, for dental evaluation and management of his oral health condition. He had melena 1 day prior to being admitted to the hospital and felt very weak. His past medical history revealed that he had suffered a stroke in the past 3 years. The patient's laboratory findings showed extremely low levels of hemoglobin, hematocrit, erythrocyte, mean corpuscular hemoglobin concentration, and potassium, accompanied by high levels of segment neutrophil, urea, and creatinine. A thorax radiography interpretation showed pneumonia. Anthropometry measurements showed that the patient's body weight was 43 kg, height was 174 cm, and upper-arm circumference measurement was 20 cm (66.8%). The patient looked thin, and atrophy of the arm's muscle was observed. The patient's past dental history revealed there were no regular dental check-ups done.

An extraoral examination showed that the conjunctiva was pale, the vermilion was dry and exfoliated, and the patient appeared underweight and was on oxygen [Figure 6]. Intraorally, there was obvious poor oral hygiene. Multiple gangrene radix was present, and a high viscosity of saliva was observed on the labial mucosa [Figure 7], hard palate, teeth, and dorsum of the tongue, resulting in a thickly coated tongue [Figure 8]. Edentulous areas were observed, whereas plaque and calculus were observed on all tooth surfaces in all regions.
Figure 6: Patient appeared underweight and on oxygen aids

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Figure 7: High viscosity, sticky saliva, and gangrene radix observed

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Figure 8: Coated tongue and dried saliva

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Based on the clinical findings, a diagnosis of community-acquired pneumonia, peptic ulcer due to erosive gastropathy, anemia due to loss of blood, and stroke sequelae were made for the patient's systemic condition, while xerostomia, coated tongue, and chronic generalized periodontitis described his intraoral condition. The treatment received from the internal medicine department included NaCl 0.9% i.v., lansoprazole 30 mg i.v., ceftazidime 1 gr i.v., potassium chloride 600 mg tablet orally, levofloxacin 750 mg i.v., and N-acetylcysteine 200 mg orally

The treatment plan for the intraoral condition included education and instruction to improve oral hygiene by brushing the teeth and using chlorhexidine digluconate 0.12% mouthwash regularly, cleaning the tongue and labial mucosa with saline-moist gauze, and applying Vaseline petroleum jelly on the vermilion. Family member assistance was needed to do these procedures completely. The patient also planned to have scaling, extractions, and rehabilitation with dentures done after his general condition improved. Unfortunately, the patient's general condition was deteriorating; thus, intraoral treatment was postponed.

  Discussion Top

One of the problems which may contribute to malnutrition in elderly people is inadequate nutritional intake. Several factors, such as physiological, pathological, sociological, and psychological factors, can cause the nutritional inadequacy in elderly people [Table 1].[17],[18]
Table 1: Various factors influencing nutritional inadequacy in the elderly population

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Many conditions are associated with gastrointestinal problems, such as poor dentition, swallowing, dyspepsia, esophageal reflux, constipation, and diarrhea, which may cause poor nutritional intake and malabsorption. Furthermore, some cardiovascular and pulmonary diseases may cause unintentional weight loss by increasing metabolic demand and decreasing appetite and caloric intake.[19] In the present case, the patient had poor dentition and did not wear any dentures, which may have led to eating problems that eventually caused inadequate nutrient intake. Furthermore, the malfunctioning of the teeth and inappropriate rehabilitation may cause dietary changes to foods with softer consistencies, thus limiting food choices. The longer this occurs, the more the person may lose his/her appetite and refrain from eating the appropriate foods needed to fulfill his/her nutritional requirements.

The malnutrition condition in this present case was analyzed by measuring the patient's upper arm circumference or Lingkar Lengan Atas (LILA). The normal result upper-arm circumference is 23.5 cm for female and 29.3 cm for male, whereas our patients were 20 cm. %LILA were 66.8%, which categorized into underweight (<90%). The benefit of this method is that it is easier and faster to as compared to other methods for nutritional condition of patient. Furthermore, the equipment used is simple, cheap, and easy to carry.[11],[20] According to the literature, elderly people need 2,325 calories for males and 1,900 calories for females per day,[21] whereas in this case, the patient's daily intake was estimated to be 200 calories.

The oral cavity is an important source of bacteria that may cause lung infections such as pneumonia. The oral biofilm formed in the mouth initiates the process of dental caries and periodontal disease and so influences the initiation and progression of pneumonia because of the inhalation of the biofilm into the respiratory tract. There are two colonies of bacteria that cause pneumonia; the species that normally live in the oropharynx, such as Streptococcus pneumoniae, Hemophilus influenzae, and Mycoplasma pneumoniae, which causing community-acquired pneumonia, whereas Pseudomonas aeruginosa, Staphylococcus aureus, and Enterobacteriaceae are oropharyngeal nonmembers that cause nosocomial pneumonia.[22]

One study reported that one cubic millimeter of dental plaque contains about 100 million bacteria[23] and serves as a potential reservoir of pathogens for both oral and respiratory bacteria. Other studies have assumed that oral and respiratory bacteria in the dental plaque are dropped into the saliva and then aspirated into the lungs and lower respiratory tract, where they cause infections. Inflamed periodontal tissue may induce the activation of cytokines and enzymes of inflammation that are transferred into the lungs and stimulate the inflammatory process locally, preceding a pathogen's colonization and definite lung infection.[22],[24] The inhalation of airborne pathogens or movement of bacteria from local infections through bacteremia may be another possible mechanism of pulmonary infection.[25]

In the present cases, the poor oral hygiene comprised multiple gangrene radixes, plaque, and calculi containing many bacteria pathogens that can play a role as the cause of aspirated or community-acquired pneumonia. In addition, the underlying malnutrition caused by the patients' dentition issues might have increased the susceptibility of the patients to pneumonia. Therefore, good oral hygiene condition has an important role in preventing malnutrition and pneumonia.

The management of the current condition of geriatric patients' needs an interdisciplinary approach, including the correction of malnutrition and promotion of oral hygiene. Nutritional status interventions by the Internal Medicine Department should include a dietary prescription of three main meals daily and two snacks, with adequate fiber, as well as oral supplements. Chlorhexidine digluconate 0.12% mouthwash is given to reduce the harmful oral bacteria along with instructions to maintain a healthy oral hygiene condition with regular brushing and mouth rinsing. Chlorhexidine digluconate 0.12% has an antiplaque role, as its bactericide action prevents secondary infections in oral ulcers, and it is a promising antifungal.[26] Radix extraction and mouth rehabilitation should be done once the general condition of the patient has improved. In the present case, instruction and education to maintain good oral hygiene with regular tooth brushing and rinsing with Chlorhexidine digluconate 0.12% mouthwash showed good results in reducing plaque accumulation. The medications given by the Internal Medicine Department cured the patients' respiratory infections.

  Conclusion Top

The oral bacteria which exist in plaque, calculus, and gangrene radix may play a role in causing aspirated pneumonia. Poor dentition in the elderly may contribute to generate a malnutrition condition. Oral health status has a close relationship with the risk of malnutrition and pneumonia in geriatric patients. Therefore, comprehensive management is needed to improve the quality of life of geriatric patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.


Our gratitude to Dr. Wahyu Hidayat, Sp. PM, Dr. Nanan Nur'aeny, Sp. PM, Dr. Dewi Kania Sp. PM for their help in the management of the patients.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]

  [Table 1]


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