10 Trillion Microorganisms versus Your Toothbrush


“The mouth is dirty,” Dr Kenneth Shay stated frankly; AND, it is “the biggest hole in your body!”

Warning: You may want to finish eating, brush your teeth, floss, use mouthwash, and then come back…


If it is early morning, and you haven’t brushed your teeth yet: then scrape the gunk off your teeth with your fingernail. You may have found 10 billion microorganisms in that cubic millimeter.

There are 1 trillion to 10 trillion microorganisms in your mouth. Simply brushing your teeth can get rid of that nasty bacteria film in your mouth. It can also prevent “some of that schmutz” from getting into your lungs. If you are having trace aspiration (saliva, food, and/or liquids getting into your lungs), try to make what gets into your lungs less nasty. You can prevent pneumonia. Pneumonia due to poor oral care is a major avoidable infection, per Shay.

Ross & Crumpler (2006) noted that despite strong evidence in the literature on the role of brushing the teeth in preventing pneumonia, medical staff continue to view oral care as a comfort measure and only use foam swabs.

“Toothette sponges are wimpy,” stressed Shay. They don’t get the gunk (plaque) off the teeth. Plaque is sticky. If not removed, it hardens into tarter (also known as calculus). Then a visit to the dentist is needed to get it off (debridement).

Why is the mouth forgotten in healthcare? We help the dependent elder go to the bathroom many times a day. So why don’t we help brush his teeth?I’ve heard some nurses say they are squeamish about the mouth! It makes them gag! Well, we should be gagging over the costs of neglecting the mouth.

This simple prevention technique of brushing costs pennies a day against the cost of a pneumonia. Based on CDC numbers from 2011, there were 157,500 Hospital Acquired Pneumonia infections that year. CDC states the average extra cost of that hospital acquired infection is $22,875. This equals over 3 billion dollars!

Why are we not protecting this wide open gateway to the body? Imagine your gingival space between the tooth and gum as a huge parking lot. Germs love these 1-3 millimeter deep parking spaces. If germs park in the gingival space for more than 24 hours, they become calcified into plaques. Bacterial loves to stick to plaque. Only brushing removes it. No brushing leads to a build-up of plaque in the gingival space and inflammation (gingivitis).

It only takes 48 hours of hospitalization in a critically ill patient to change this bacteria from the usual gram-positive streptococci to gram-negative microorganisms (the nasty pathogenic bacteria that cause pneumonia).
Maybe we don’t brush our patients teeth because the gums bleed? Blood is okay, per Shay, even if you are on a blood thinner. Shay stated that bleeding is a sign that you need to brush more. It is due to the inflammation, and regular brushing will prevent bleeding. Shay warned that bleeding is only risky if the patient has a blood disorder or disease that causes excessive bleeding.

Most cases of gingivitis do not progress to the more serious periodontitis, but…Immune-compromising events can cause an autoimmune response that can lead to periodontitis, per Shay. Examples of immunocompromising events are not only hospitalization and critical illness; they could also be the following:

• life stressors
• flu
• depression, and
• pregnancy

Periodontitis is inflammation caused by bacteria that affects the attachment between the tooth and the bone. It is an irreversible destruction of the supporting tissues (i.e., the periodontal ligament to alveolar bone). Then bone-absorbing cells eat away at the bone. The bone will not be regenerated. Additionally, with the gums receding, “there is more surface area to collect gunk,” said Shay. The periodontal pocket that is formed creates a larger “parking garage” of 6-8 millimeters deep. Lots of gram-negative anaerobic bacteria can park there! Pathogenic microorganisms. “These are the same things that cause aspiration pneumonia,” stated Shay.

See the full blog post at www.swallowstudy.com.

Karen Sheffler, MS, CCC-SLP, BCS-S, graduated from the University of Wisconsin-Madison in 1995 with her master’s degree. There, she was under the influence of the great mentors in the field of dysphagia like Dr. John (Jay) Rosenbek, Dr. JoAnne Robbins, and Dr. James L. Coyle. Once the “dysphagia bug” bit, she has never looked back. Karen has always enjoyed medical speech pathology, working in skilled nursing facilities and rehabilitation centers in the 1990s, and now in acute care in the Boston area for more than 14 years. She has trained graduate student clinicians during their acute care internships for more than 10 years. Special interests include neurological conditions, esophageal dysphagia, geriatrics, end-of-life considerations, and patient safety/risk management. She has lectured on various topics in dysphagia in the hospital setting, to dental students at the Tufts University Dental School, and on Lateral Medullary Syndrome at the 2011 ASHA convention. She is a member of the Dysphagia Research Society and the Special Interest Group 13: Swallowing and Swallowing Disorders. Karen obtained her BCS-S (Board Certified Specialist in Swallowing and Swallowing Disorders) in August of 2012. You can follow her blog, www.swallowstudy.com.


  1. Judy Matsumoto says

    How do you brush their teeth when they cannot spit back toothpaste? Do you brush them without toothpaste?

  2. says

    Thank you for answering that question Todd!
    If you do not have a toothbrush hooked up directly to a suction (i.e., SAGE products), you could carefully brush and use a Yankauer suction at the same time.

    Further thoughts:

    If you have no toothpaste available, then per Dr Ken Shay (at his lecture at the April ASHA Healthcare and Business Institute): brushing is better than no brushing at all. It takes the scrubbing action of a toothbrush to remove the plaque. You could dip the toothbrush into the mouthwash solution available, and suction out debris and residue with a yankauer suction.

    I know there may be nursing home rooms with no suction available. I guess the best would be brush with toothbrush and use lots of clean swabs with the extra water squeezed out, and swab forward and out to remove all debris and residue. Of course, have the patient sitting fully upright with chin down to make sure nothing trickles down the throat. Having an extra staff member will help for extra hands. Gently talk the patient through the process in a calming voice. No one likes this process; however, I have found that even very confused patients can be cooperative and appreciative. Especially when they can feel the difference.

    I have found large “sheets” of debris adhered to the hard and soft palates and tongue in NPO patients when no oral care has been performed in days. Two tongue depressors can act as gentle tweezers. We have to be very careful when we are gently debriding the mouth. Prior to performing this in cases of severely poor oral hygiene, contact the primary MD to let her/him know the condition. The MD will know if the patient is a bleeding risk (i.e., checking INR, platelets, etc). If the need for debridement is too extensive, then the MD will make appropriate referrals (i.e., ENT, Dentist). However, there have been times when the material is large enough to cause actual choking if the sheet of debris breaks off and is attempted to be swallowed. This needs to be addressed immediately. We may be the only people to look up at the hard palate. We are key people in this patient safety issue. If the person is NPO, weak, and lethargic, he/she has minimal lingual stripping action to clean off the hard palate and tongue. Debris accumulates there within a day or two. We cannot do our p.o. trials for our bedside swallow evaluation on a patient with a nasty mouth. That would only add to the problem. A clean and clear mouth has to come first.

    I know this is very tricky, especially with our less cooperative patients. However, it is important to know this factor when the team is trying to find the primary source of the aspiration pneumonia. We can contribute to the discussion by reporting the patient’s poor oral hygiene and dependency on others for good oral care. The patient may not be aspirating food and liquid significantly enough to warrant a diet modification. The main issue may be the dentition and poor oral hygiene. It just takes aspirating a little of the saliva that is full of gram-negative bacteria. No matter what we do to the diet, we will not change the root cause or source of infection.

    We can stress the importance of brushing and the use of a mouthwash like chlorhexidine (Peridex). Note: this mouthwash is used AFTER brushing, as it’s effects last for hours. Make sure the patient does not eat immediately after rinsing with this mouthwash. Make sure the patient spits it out after rinsing. Again, for patients who cannot follow commands, we should use swabs to apply the mouthwash and suction out the residue with yankauer suction catheters. Staff should not pour a cup of the mouthwash into the mouth of a dependent patient.

    Thanks for reading! I look forward to more comments/ideas/questions.