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. 2020 Nov 6:11:528056.
doi: 10.3389/fneur.2020.528056. eCollection 2020.

Oral Health, Oral Microbiota, and Incidence of Stroke-Associated Pneumonia-A Prospective Observational Study

Fabian Cieplik  1 , Alma Maria Wiedenhofer  1   2   3 , Verena Pietsch  1   2   3 , Karl-Anton Hiller  1 , Andreas Hiergeist  2 , Andrea Wagner  3 , Dobri Baldaranov  3 , Ralf A Linker  3 , Jonathan Jantsch  2 , Wolfgang Buchalla  1 , Felix Schlachetzki  3 , André Gessner  2
Affiliations

Oral Health, Oral Microbiota, and Incidence of Stroke-Associated Pneumonia-A Prospective Observational Study

Fabian Cieplik et al. Front Neurol. .

Abstract

Stroke-associated pneumonia is a major cause for poor outcomes in the post-acute phase after stroke. Several studies have suggested potential links between neglected oral health and pneumonia. Therefore, the aim of this prospective observational study was to investigate oral health and microbiota and incidence of pneumonia in patients consecutively admitted to a stroke unit with stroke-like symptoms. This study involved three investigation timepoints. The baseline investigation (within 24 h of admission) involved collection of demographic, neurological, and immunological data; dental examinations; and microbiological sampling (saliva and subgingival plaque). Further investigation timepoints at 48 or 120 h after baseline included collection of immunological data and microbiological sampling. Microbiological samples were analyzed by culture technique and by 16S rRNA amplicon sequencing. From the 99 patients included in this study, 57 were diagnosed with stroke and 42 were so-called stroke mimics. From 57 stroke patients, 8 (14%) developed pneumonia. Stroke-associated pneumonia was significantly associated with higher age, dysphagia, greater stroke severity, embolectomy, nasogastric tubes, and higher baseline C-reactive protein (CRP). There were trends toward higher incidence of pneumonia in patients with more missing teeth and worse oral hygiene. Microbiological analyses showed no relevant differences regarding microbial composition between the groups. However, there was a significant ecological shift over time in the pneumonia patients, probably due to antibiotic treatment. This prospective observational study investigating associations between neglected oral health and incidence of SAP encourages investigations in larger patient cohorts and implementation of oral hygiene programs in stroke units that may help reducing the incidence of stroke-associated pneumonia.

Keywords: oral health; oral microbiota; pneumonia; stroke; stroke care; stroke-associated pneumonia.

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Figures

Figure 1
Figure 1
Flow of patients.
Figure 2
Figure 2
Culture-dependent analysis. Genera detected by culture-dependent matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) analysis. Relative abundancies of the 10 most abundant genera overall and the five most abundant genera additionally found in pneumonia patients at 120 h after baseline are depicted, per patient group and investigation timepoint (STR, Streptococcus; NEI, Neisseria; PRE, Prevotella; ROT, Rothia; HAE, Haemophilus; FUS, Fusobacterium; VEI, Veillonella; LEP, Leptotrichia; STA, Staphylococcus; ACT, Actinomyces; CIT, Citrobacter; ENT, Enterococcus; KLE, Klebsiella; ALL, Alloscardovia; CAN, Candida).
Figure 3
Figure 3
Beta diversity analysis from 16S rRNA amplicon sequencing. (A) Principal coordinate analysis (PCoA) of weighted UniFrac distances for analyzed samples from stroke mimics and stroke patients at baseline (BL) as well as for stroke-associated pneumonia patients at BL and at 48 and 120 h after BL. Ellipses indicate the 95% confidence interval of group centroids. (B) Discriminatory operational taxonomic units (OTUs) for stroke mimics, stroke patients, and stroke-associated pneumonia patients at BL, as revealed from linear discriminant analysis (LDA) effect size (LEfSe) analysis. (C) PCoA of unweighted UniFrac distances for the stroke-associated pneumonia patients over time at BL and at 48 and 120 h after BL (indicated by arrows for each individual patient). (D) Significantly differentially abundant OTUs in stroke-associated pneumonia patients between BL and 120 h after BL, as detected by DESeq2.
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