JCPSLP Vol 20 No 3 November 2018

Nutrition, swallowing, mealtimes: Recipes for success

Basic oral care for patients with dysphagia A Special Needs Dentistry perspective Mathew Albert Wei Ting Lim

Oral health is known to be a factor contributing to health-related quality of life in the general population. However, it is particularly important for the health and outcomes of people with dysphagia, especially those at risk of aspiration. Despite poor oral hygiene being considered a modifiable risk factor, oral health professionals such as specialists in special needs dentistry may have limited involvement in the multidisciplinary care of individuals with dysphagia. This article offers a special needs dentistry perspective on the considerations and approaches to oral care for people with dysphagia. Several techniques often used by specialists in this field, ranging from oral hygiene protocols to dental treatment, will be discussed. Strategies for daily oral hygiene regimes, which can be easily adapted and individualised by carers, support workers, nursing and allied health professionals in the absence of oral health practitioners, are presented. Ultimately, however, this article aims to facilitate discussion and promote increased collaboration between speech- language pathologists and oral health professionals in the management of individuals with dysphagia. I n addition to playing an important role in mastication, a person’s dentition can also be central to self- image and contribute to quality of life. Unfortunately, many approaches used in the management of oral and pharyngeal dysphagia can place the oral cavity at greater risk of disease. For example, dietary modification techniques (such as alteration of food texture or thickening of fluid) used to alter bolus or liquid flow and compensate for compromised swallowing function, can increase oral retention and in doing so facilitate growth of oral microorganisms that lead to dental decay. Dental decay (caries) occurs because of a dynamic, complex, and multifactorial process that arises from the continual loss of mineral ions from the tooth surface. One of the most significant risk factors leading to this process is the production of acids by microorganisms in the plaque

(Mount & Hume, 2005). Stagnation of food in the oral cavity increases risk of dental decay; however, this is exacerbated by nutritional fortification of foods. Increased carbohydrate content or the use of starches or simple carbohydrates to thicken fluids (frequently granulated maize starch [maltodextrin] or gums [xantham]) are highly cariogenic and can hasten and accentuate demineralisation of the tooth surface (Mount & Hume, 2005; O’Leary, Hanson, & Smith, 2010). Prolonged accumulation of plaque may also predispose patients to gum (periodontal) disease. Oral health and dysphagia The importance of oral health in contributing to overall systemic health is often overlooked. Research in recent years has highlighted the importance of optimal oral care in mitigating the problems associated with dysphagia, particularly individuals at risk of aspiration (Eisenstadt, 2010; Langmore et al., 1998; Martin et al., 1994). Aspiration occurs when foreign material, including food debris, saliva, and plaque, descends into the bronchial tree and lung alveoli (Müller, 2014; Scannapieco & Mylotte, 1996). Aspiration pneumonia is a serious complication of this process. Aspiration pneumonia has been reported to be a leading cause of death and hospitalisation among residents in nursing homes and the underlying cause of just under 1% of all Australian deaths (Australian Bureau of Statistics, 2014; Terpenning, 2005). Dysphagia is a recognised a risk factor for aspiration pneumonia, however, studies have shown that it alone is generally not sufficient to cause pneumonia unless other risk factors are also present (Langmore et al., 1998). Such risk factors include poor oral hygiene, periodontal disease, untreated dental disease, and nocturnal denture wearing (Müller, 2014). Oral plaque has been identified as a potentially modifiable risk factor in 10.3% of pneumonias requiring hospitalisation in community-dwelling older adults (Juthani-Mehta et al., 2013). Likewise, nocturnal denture wearing, which due to the associated increase in oral microbial burden, has been found to present a comparable risk of developing pneumonia as a history of swallowing difficulties, stroke, or respiratory disease (Iinuma et al., 2014). Oral hygiene is therefore a critical element of preventing serious sequelae. Oral hygiene Maintenance of good oral hygiene has been shown to decrease the risk of aspiration pneumonia across several clinical settings ranging from residential aged-care facilities

KEYWORDS ASPIRATION PNEUMONIA DENTISTRY DYSPHAGIA

ORAL HEALTH ORAL HYGIENE

THIS ARTICLE HAS BEEN PEER- REVIEWED

Mathew Albert Wei Ting Lim

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JCPSLP Volume 20, Number 3 2018

Journal of Clinical Practice in Speech-Language Pathology