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Oral hygiene in patients with chronic obstructive pulmonary disease: a scoping review protocol

Pedersen, Preben U.1; Uhrenfeldt, Lisbeth2; Larsen, Palle1

JBI Database of Systematic Reviews and Implementation Reports: May 2017 - Volume 15 - Issue 5 - p 1236–1241
doi: 10.11124/JBISRIR-2016-003047

Scoping review objective: It is hypothesized that systematic oral hygiene may reduce airway infections in patients with chronic obstructive pulmonary disease (COPD). Before considering doing a systematic review, a scoping review is necessary to explore and map literature on the subject and identify which interventions have been carried out, if there is relevant literature available for a systematic review, or if further research should be initiated.

The objective of this scoping review is to comprehensively identify and describe qualitative or quantitative literature reporting of non-invasive interventions that have been carried out to improve oral hygiene and relieve and/or reduce respiratory tract infections, exacerbation and/or hospital readmission in patients with diagnosed with COPD. A further objective is to undertake a comprehensive search to identify qualitative literature reporting on the experiences of oral hygiene in people diagnosed with COPD and/or their relatives and/or healthcare providers (HCPs).

Specifically, the scoping review questions are as follows:

  • What non-invasive interventions have been carried out to improve oral hygiene in patients with COPD in any context?
  • What have been reported on the experiences of patients, their relatives or their HCP in relation to oral hygiene in patients with COPD?

1Danish Center of Systematic Review: a Joanna Briggs Institute Centre of Excellence, Centre of Clinical Guidelines, Aalborg University, Aalborg, Denmark

2Department of Health Science and Technology, Aalborg University, Aalborg, Denmark

Correspondence: Preben U. Pedersen,

There is no conflict of interest in this project.

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Many countries currently implement policies to increase care quality while controlling costs for the treatment and care of patients with chronic conditions.1 Cardiovascular disease, diabetes and chronic obstructive pulmonary disease (COPD) are among the most common chronic conditions.2 Chronic obstructive pulmonary disease is one of the leading causes of mortality, and acute exacerbations contribute substantially to this.2 It was the fifth leading cause of death in 2002 and is predicted to rank third by 2020.3 Among patients discharged after an exacerbation in COPD, one in five will require re-hospitalization within 30 days.1 Chronic obstructive pulmonary disease is associated with a significant economic burden, including hospitalization, work absence and disability in patients.2 Current data suggest that COPD mortality is increasing, and by 2020 COPD is predicted to be the third leading cause of death worldwide.4

There is a general association between oral microorganism and respiratory tract infections.5 Multiple defense mechanisms operate within the healthy respiratory tract to eliminate aspirated bacteria, but their effectiveness can be impaired by a variety of conditions such as malnutrition, smoking, COPD, diabetes or use of corticosteroids.6 Teeth or dentures have non-shedding surfaces on which plaque forms. Plaque is susceptible to colonization by respiratory pathogens.7 The pathogens present in the oropharyngeal secretion of an individual with oral disease can be particularly dangerous if aspirated into the lungs, especially those of a medically compromised patient.5,6,8 A study has indicated that patients with confirmed COPD seem to have a higher degree of pathogenic microorganisms in denture plaque (90% versus 64%) than healthy controls.9 In another study, in hospital admissions, patients with COPD had poorer periodontal health, a higher prevalence of gingival inflammations and lower tooth brushing frequency compared to a control group.10 Fewer remaining teeth, a higher score for dental plaque and low tooth brushing frequency are significantly correlated to COPD exacerbations.11

Based on two systematic reviews, there is good evidence8,12 that improved oral hygiene and frequent professional oral health care can reduce the progression or occurrence of respiratory diseases among high-risk elderly adults (number needed to treat = 2 to 16; relative risk reduction = 34 to 83%) and in patients undergoing thoracic surgery (RR 0.54, 95% CI 0.42, 0.70).8,12

Oral interventions that improve oral hygiene through mechanical and/or topical chemical disinfection or antibiotics reduce the incidence of nosocomial pneumonia by an average of 40%.6 In patients with COPD, interventions to improve oral health and oral hygiene suggest that periodontal therapy may improve lung function, decrease the frequency of COPD exacerbation and improve quality of life.13

Unlike other chronic conditions, the efficacy of interventions aimed at preventing hospitalizations due to exacerbations in clinically stable COPD is debatable. Some studies have reported14,15 the effectiveness of patient empowerment for self-management in patients with moderate to severe COPD. It is hypothesized that the severity of the disease, concomitant factors, such as comorbidities, patients’ anxiety/depression, uncovered social needs and poor self-management of the disease may modulate hospitalization rates due to airway infections or exacerbations in these patients.16 Lower brushing frequency, poor oral health and the presence of destructive periodontal disease have been observed among patients with COPD, which warrants promoting dental care and oral health knowledge as an integrated approach to treating COPD patients.17 Furthermore, self-care activities based on a protocol to improved oral health care have showed significant improvements in oral health in patients with COPD.18

At a summit involving patients, clinicians, researchers, policy makers and representative of healthcare centers, it was concluded that programs to reduce hospitals admission should include at least specific recommendations on how to promote COPD self-management skills training for patients and their care givers.19

Self-management of the disease focuses on interventions that patients themselves can carry out during their daily routines and that reduce the progression of the disease, decrease the risk of complications and increase quality of life. It is the responsibility of all healthcare providers (HCPs) to help maintain oral health in individuals and to assist those with poor oral health habits to improve their oral health habits, based on the best available evidence.

In the literature, it was found that patients themselves have tried various strategies for limiting their symptoms due to COPD. However, none of the strategies mentioned included oral hygiene. The reported strategies included smoking cessation, adapting activities to breathlessness, pacing activities to conserve energy and taking more rest.20 Perceptions of COPD by family members have been shown to pose a challenge to self-care for some patients.20

In a study examining how nursing-home staff experienced assisting patients with oral health care, it was found that oral health care had a low priority in nursing. The in-depth interviews showed that the quality of the oral health care received by the patients depended on several factors. It was found that often there was no specific routine for oral health care in the nursing homes and that other activities were given higher priority. Assisting oral health care was described as passing a barrier, in which the main aim was to gain access to the oral cavity.21

An initial search performed in 2016 in CINAHL, JBI COnNECT+, DARE, MEDLINE, Cochrane Library and PROSPERO showed that no scoping review or systematic review on this topic had been published. A review from 2006 focused on oral hygiene in frail elderly nursing home residents or patients admitted to intensive care units.8 In a systematic review published in 2016, it was concluded that systematic oral hygiene in the perioperative period after thoracic surgery reduced airway infections.12 Some studies indicate that improved oral hygiene in patients with COPD could reduce some of the complications patients experience,17,18 and two systematic reviews including other patients with other diagnoses support the hypothesis that systematic oral hygiene may reduce airway infections in patients with COPD. Therefore, before conducting a systematic review, a scoping review is necessary to explore the literature on the subject and identify whether relevant literature is available for the conduct of a systematic review or whether the approach should be further researched.

The Joanna Briggs Institute (JBI) guidance for the conduct and reporting of scoping reviews has been adhered to in the preparation of the present protocol and will be followed throughout the ensuing review.22

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Inclusion criteria

Type of participants

In this scoping review, there will be three types of adult participants: patients with COPD, their relatives and/or HCPs involved in oral hygiene.

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The core concept examined by this scoping review is oral hygiene in patients with COPD. Oral hygiene as an intervention is understood as any intervention patients with COPD can carry out by themselves and/or with assistance by their relatives and/or HCPs. Systemic interventions (e.g. pharmacological) or invasive interventions (e.g. dental extractions) will not be considered as a relevant intervention to be included in this systematic review. Any experiences with oral hygiene in patients with COPD, reported by patients themselves, their relatives or HCP staff, will be of interest in this scoping review.

Chronic obstructive pulmonary disease is a lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible. A COPD diagnosis is confirmed by a simple spirometry test. Spirometry is the gold standard for diagnosing and monitoring progression of COPD that is defined by irreversible lung function impairment with a reduced FEV1/vital capacity ratio. However, differences in the definition of COPD in guidelines and consensus statements make it difficult to quantify the morbidity and to make comparisons between countries. In addition, there are different recommendations in the major guidelines and consensus statements concerning how to perform spirometry.23 Studies will be included if authors provide information on how patients have been diagnosed; otherwise, the studies will be excluded.

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The context is any setting in which interventions or experiences of oral hygiene have occurred (e.g. at home, nursing homes or other care facilities).

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Type of sources

The sources of information include both quantitative and qualitative data from any existing literature, for example, primary research studies and systematic reviews. The scoping review will consider both systematic reviews (including any experimental and observational study design), including randomized controlled trials, non-randomized controlled trials, quasi-experimental studies, before and after studies, prospective and retrospective cohort studies, case control studies, and analytical and descriptive cross-sectional studies.

The qualitative part of this review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenological, grounded theory, ethnography, actions research and feminist research.

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Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review as recommended by JBI.24

The initial search strategy and terms will be chosen in discussion with a research librarian with the aim of identifying the maximum number of articles. An initial limited search of MEDLINE (via PubMed) and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases, and citation searches will also be carried out. Third, the reference lists of all identified reports and articles will be searched for additional studies. Studies published in English, German, Danish, Swedish and Norwegian will be considered for inclusion in this review. Databases will be searched from their inception. Where relevant, the reviewers will contact authors of primary studies or reviews for further information.

The databases to be searched include: MEDLINE (via PubMed), CINAHL, Embase, Scopus, Mednar (for gray literature), CDC, MEDION, Health Technology Assessment Database, Turning Research Into Practice (TIP), NTIS, ProQuest Dissertations and Theses, and Google Scholar.

Initial keywords/search terms to be used will be:


Oral care

Oral hygiene




Respiratory tract infections





Self-care activities

Nursing home

Care facility




Significant others

Loved ones

Healthcare providers/professionals

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Data extraction

Data extraction of both quantitative and qualitative data will be carried out by two of the authors independently, and differences will be resolved through a third reviewer. Data will be presented using a data extraction tool developed by the authors: one for primary quantitative studies and one for primary qualitative research (Appendix I). The data extraction tool will be amended to suit the particular purpose/objective for this review. Extraction from non-English literature will be translated to English, and the original text in the native language will be provided in brackets after the text in English.

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Presenting the data

Data extracted from each of the studies will be mapped and presented in a form that logically reflects the objectives of this scoping review. Tabular and graphical representations of the data may be used to illustrate the identified results and will be supported with narrative descriptions of the data. The data from the studies will be presented and discussed in terms of overall concept/components that related to interventions of oral hygiene used among people with COPD as well as their experiences and experiences of relatives and HCPs.

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Appendix I: Extraction of findings

Primary quantitative research



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Primary qualitative research



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Chronic obstructive pulmonary disease; oral care; oral hygiene; prevention

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