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FACT SHEET: Pneumonia (also known as “bronchopneumonia” and “walking pneumonia”1; caused by various types of bacteria2, viruses3, fungi4, and mycoplasma5)

Date of Publication: January 22, 2024
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Note: Aspiration pneumonia (along with foreign body aspiration) is specifically addressed in the separate Aspiration Syndromes fact sheet.

Is the initiation of non-invasive dental hygiene procedures* contra-indicated?

Yes, if the patient/client has active disease and/or is contagious.

Is medical consult advised?

  • If a patient/client exhibits signs and symptoms of pneumonia (see below), refer to primary care provider (e.g., physician or nurse practitioner) for definitive diagnosis (clinical examination +/- imaging +/- laboratory)6 and management. The patient/client should be instructed to reschedule dental hygiene appointment when the person feels well and is non-infectious.

Is the initiation of invasive dental hygiene procedures contra-indicated?**

  • Yes, if the patient/client has active disease and/or is contagious.

Is medical consult advised?

  • See above.

Is medical clearance required?

  • No.

Is antibiotic prophylaxis required?

  • No (although antibiotics may be required for treatment of bacterial pneumonia).

Is postponing treatment advised?

  • Yes, during the period of communicability (see below).

Oral management implications

  • Mode of transmission is usually via contact with respiratory secretions (e.g., sputum and nasal mucus) of infected people. Infection occurs mainly by droplet spread (e.g., coughing, sneezing, and talking); these droplets can land in the mouths or noses of nearby persons. Less commonly, persons may acquire pneumonia by touching surfaces or objects that have the causative microorganism on them, and in turn touching their own mouth or nose.
  • The degree of contagiousness and period of infectivity are dependent on the specific microbial cause and the underlying reasons for development of pneumonia.7 Generally, if one has bacterial pneumonia, one is contagious for around 48 hours after starting antibiotics and until fever has dissipated. For viral pneumonia, as signs/symptoms start to go away (especially fever), contagiousness to others diminishes. Pneumonia caused by fungi is usually not contagious.
  • Some types of pneumonia are vaccine preventable or at least vaccine modifiable. Annual influenza immunization is recommended for most persons. Additionally, eligible persons (including patients/clients and healthcare providers, as appropriate) should also consider vaccinations against COVID-198, Streptococcus pneumoniae bacterium9, respiratory syncytial virus (RSV)10, and Haemophilus influenzae type B (Hib) bacterium11.
  • Frequent handwashing and judicious wearing of high-quality respiratory masks decrease risk of contracting microorganisms responsible for causing pneumonia.
  • Poor oral and denture hygiene, as well as xerostomia, may be associated with bacterial pneumonia (and oral candidiasis).
  • People who smoke are at higher risk of developing pneumonia, and children of parents who smoke are also at elevated risk. Dental hygienists should counsel patients/clients who smoke to stop smoking and refer them to cessation supports in their local communities (e.g., public health unit, smokers’ help line, etc.). In Ontario, the Canadian Cancer Society offers a free, confidential Smokers’ Helpline for smokers via Telehealth Ontario at 1-866-797-0000 or 1-877-513-3333; Smokers’ Helpline Online is available at smokershelpline.ca.
  • Oral care recommendations for prevention of pneumonia in patients/clients who are elderly or frail include: removal and cleaning of dentures daily, as well as refraining from wearing them while sleeping; and brushing after meals to disrupt bacterial plaque, as well as using floss or interdental cleaner once per day.
  • Oral care recommendations for prevention of pneumonia in patients/clients who are ventilated include: minimization of pooling of secretions through regular drainage and suction; elevation of patient/client’s head to 30 to 45 degrees; brushing teeth twice daily; and using a foam swab with chlorhexidine12 gel or rinse to debride oral cavity every 2 to 4 hours.
  • Protocols for oral care for intubated patients/clients should be actively promoted. Oral care kits are commercially available to help prevent ventilator-associated pneumonia (VAP). Such kits frequently include toothbrushes, oral swabs, chlorhexidine, and oral gel specifically designed for the intubated patient/client, and some kits include recommended daily regimens.

Oral manifestations

  • Halitosis and/or expectoration of sputum may be present.
  • Lips may be cyanotic (bluish in colour) due to lack of oxygen in the blood.
  • Oral candidiasis in an immunocompromised patient/client with signs/symptoms of pneumonia may be an indicator of an opportunistic fungal pneumonia or even bacterial pneumonia.

Related signs and symptoms

  • Pneumonia is an infection of the lungs that inflames the alveoli.13 The alveolar air sacs may fill up with fluid or pus.
  • Pneumonia can be broadly classified into two types: community-acquired pneumonia (CAP) and nosocomial (hospital or healthcare acquired) pneumonia (NAP or HAP). CAP is usually associated with pathogens that normally reside on the mucosa of the oropharynx or nasopharynx. Nosocomial pneumonia includes the sub-type ventilator-associated pneumonia (VAP), which results from intubation and mechanical ventilation.14
  • Anatomically, pneumonia may occur as lobar pneumonia (that affects one or more sections of the lungs) or bronchopneumonia, also known as bronchial pneumonia (that affects patches throughout the lungs). The right lower lobe is the most common site for aspiration pneumonia due to its vertical orientation.
  • Pneumonia is the leading infectious cause of death in developed countries such as Canada. Annually in Ontario, pneumonia causes about 2,000 deaths and results in more than 250,000 healthcare utilization episodes.
  • Signs and symptoms of pneumonia vary from barely noticeable to so severe that hospitalization is required. Response to pneumonia depends on the causative microbe, age15, and overall health.
  • Signs/symptoms may include:
    • cough (which may produce green, yellow, or even bloody sputum)
    • fever, sweating and chills
    • dyspnea (shortness of breath)
    • elevated respiration rate with shallow breathing
    • chest pain — often stabbing or sharp in character — that worsens with deep inspiration or coughing
    • fatigue
    • decreased appetite
    • confusion (particularly in older persons)
    • nausea and vomiting (particularly in young children).
  • Bacterial pneumonia is the most common form of pneumonia, and it tends to be the most serious kind. Onset of signs/symptoms can be gradual or extremely rapid. High grade fever (with body temperature approaching 41° C) may occur, along with profuse sweating, markedly increased respiration and pulse rates. Lips and nailbeds may be cyanotic.
  • Viral pneumonia typically has signs/symptoms that develop over a period of several days. Early manifestations often resemble those of influenza, including dry cough, headache, muscle aches, and weakness. Over a few days, signs/symptoms worsen, with increased cough, dyspnea, and muscle pain. High fever and cyanosis of the lips may occur.
  • While most people recover from pneumonia within a week to a month or more, possible complications include:
    • respiratory failure, which requires mechanical assistance or a ventilator
    • sepsis16, which may lead to widespread organ failure
    • lung abscesses, sometimes requiring surgical drainage
    • acute respiratory distress syndrome (ARDS)17.
  • Pneumonia can be life-threatening, particularly in infants, the elderly, and persons with co-morbidities such as immunosuppression or underlying respiratory disease (such as chronic obstructive pulmonary disease,  asthma, and cystic fibrosis).

References and sources of more detailed information


Date: January 13, 2024
Revised:


FOOTNOTES

1 Walking pneumonia is a relatively mild form of community-acquired pneumonia. It is often caused by Mycoplasma pneumoniae.
2 Bacterial causes of pneumonia include: 1/ aerobic bacteria, such as Streptococcus pneumoniae (most common), Haemophilus influenzae, Staphylococcus aureus (including methicillin resistant Staphylococcus aureus, also known as MRSA), and Pseudomonas aeruginosa; and 2/ anaerobic bacteria (classically associated with the oral cavity), including Bacteroides, Fusobacterium, Peptostreptococcus, and Prevotella.
3 Viral causes of pneumonia include influenza, COVID-19 (SARS-CoV-2), and respiratory syncytial virus (RSV).
4 Fungal causes of pneumonia (which are relatively uncommon) include: 1/ opportunistic fungal organisms (of particular concern to immunocompromised persons), such as Candida species, Aspergillus species, and Pneumocystis jiroveci (previously named Pneumocystis carinii, and classically associated with AIDS); and 2/ endemic fungal pathogens (which cause infection in healthy hosts as well as immunocompromised persons), such as Histoplasma capsulatum, Coccidioides immitis, Blastomyces dermatitidis, Cryptococcus neoformans, and Sporothrix schenckii.
5 Mycoplasma is a genus of “atypical” bacteria. Mycoplasma pneumoniae is a common cause of community-acquired pneumonia.
6 Diagnostic tests may include chest x-ray, sputum tests, blood tests, and pulse oximetry (to measure blood oxygen level). In high-risk or hospitalized patients/clients, additional tests may include CT scan, arterial blood gases, bronchoscopy, and pleural fluid culture.
7 Treatment of pneumonia depends on the cause of pneumonia, how severe signs/symptoms are, and one’s overall health status. Treatment may include medication (antibiotics, antivirals, or antifungals) and supplemental oxygen.
8 Immunization guidelines regarding SARS-CoV-2 (the continually mutating strain of coronavirus responsible for COVID-19 disease) are continually evolving in light of new knowledge and advances in vaccine development. At the time of writing, it appears that ongoing periodic immunization against this evolving pathogen will be required indefinitely.
9 Several types of vaccines are available in Ontario for prevention of pneumoccal pneumonia and invasive pneumoccal disease (IPD), and ongoing vaccine development in this area is achieving broader serotype coverage and enhanced efficacy. Publicly funded vaccine is available for children and adults aged 65 years and older as part of the routine vaccine program (although certain vaccines are authorized in Canada for adults aged 18 years of age and older), as well as for persons qualifying for the high risk vaccine program.
10 At the time of writing, a new RSV vaccine was recently authorized in Canada for adults aged 60 years and older; it is publicly funded in Ontario for certain high-risk older adults.
11 In Ontario, Hib vaccine is publicly funded for children as part of the routine vaccination program, as well as for persons qualifying for the high-risk vaccine program.
12 Conflicting evidence exists around benefits and risks of oral decontamination protocols with chlorhexidine or topical oral antibiotics in ventilated patients/clients.
13 Alveolar inflammation can also less commonly result from non-infectious causes, such as chemical irritants (including gastric acid). This is termed pneumonitis.
14 Common microbes responsible for VAP include Haemophilus influenzae and Streptococcus pneumoniae. Biofilm develops on the endotracheal tube and can migrate to the lower airway.
15 Newborns and infants may not show overt signs of infection. Older adults and persons with serious comorbidities or who are immunosuppressed may have fewer and milder symptoms, and they sometimes have a lower than normal temperature. Persons who already have chronic lung disease, including chronic obstructive pulmonary disease, may have increased symptomatology.
16 Sepsis is a condition in which the immune system has a dangerous reaction to infection, resulting in extensive inflammation throughout the body.
17 ARDS is a life-threatening lung injury in which fluid leaks into the lungs, resulting in laboured breathing and decreased oxygenation of blood. Most persons who develop ARDS are already hospitalized for severe illness or trauma.


* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.
** Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.