JCPSLP Vol 20 No 3 November 2018

to neurologic intensive-care units (Fields, 2008; Hua et al., 2016; Juthani-Mehta et al., 2013; Watando et al., 2004). The Centers for Disease Control and Prevention recommend that a comprehensive oral hygiene program should be developed and implemented for all patients being treated in an acute care setting and residents of long-term care facilities with the aim of reducing the risk of pneumonia (Tablan, Anderson, Besser, Bridges, & Hajjeh, 2004). Similar recommendations in Australia, particularly within the aged-care setting, were advocated for and remain the legacy of the late Jane Chalmers (Chalmers, 2003; Fricker & Lewis, 2009). In addition to preventing and modulating the microbial colonisation of the oropharynx, evidence suggests that oral hygiene may increase cough reflex sensitivity and thus reduce the risk of aspiration (Tablan et al., 2004; Watando et al., 2004). Studies of the nature and effectiveness of oral hygiene interventions have largely investigated three areas: (a) mechanical cleaning of the dentition, (b) the use of chemical agents, and (c) assistance or professional oral care. Mechanical removal of plaque and food debris from the dentition and prostheses has consistently been found to reduce pneumonia risk (van der Maarel-Wierink, Vanobbergen, Bronkhorst, Schols, & de Baat, 2013). The effectiveness of using chemical agents, such as chlorhexidine, has shown more variable outcomes with greatest efficacy noted in patients who are ventilator- dependent or receiving non-oral feeding (Hua et al., 2016; Müller, 2014). Provision of oral hygiene assistance by either a trained carer or oral health professional, at least weekly, has been consistently shown to reduce oral microbial burden and risk of pneumonia (Sjögren, Nilsson, Forsell, Johansson, & Hoogstraate, 2008). Despite strong evidence supporting the importance of promoting and maintaining oral hygiene, insufficient data exists regarding the relative effectiveness of strategies that aim to either manage swallowing problems or address oral hygiene (Loeb, Becker, Eady, & Walker-Dilks, 2003). Given the diverse aetiologies that may result in swallowing difficulties, it is unlikely that a single management strategy is likely to be effective; rather a multidimensional and multidisciplinary approach may better address all salient factors. Multidisciplinary collaboration encourages greater communication between professionals, person-centred problem solving, potentially more efficient and effective use of resources, enhanced client outcomes and increased client satisfaction (Epstein, 2014). Multidisciplinary collaboration and the role of the specialist in special needs dentistry Across a range of settings, people with dysphagia should benefit from access to the collective expertise of a team of health professionals and a coordinated approach to care (Jessup, 2007; Wagner, 2000). However, the involvement of oral health professionals, such as specialists in special needs dentistry, in the management of individuals with dysphagia has been limited (Lim & Borromeo, 2017). The reasons for this may be reflective of the lack of integration of dental services into general health care in the Australian health system, the historical separation of medicine and dentistry in many parts of the world, the lack of interest and advocacy on the part of oral health professionals, or the perception that dentists would be unlikely to make a valuable contribution in this area of practice. Despite growing evidence to support the importance of good oral health to

overall well-being and quality of life, specialised oral health care for many individuals, including those with dysphagia, is often separate from their multidisciplinary management or is conducted by members of other professions such as nursing or speech-language pathology (SLP). Special Needs Dentistry (SND) as a dental specialty was established in 2003 with the aim to assist in bridging the gap between dentists and other health professionals (Chalmers, 2004; Lim & Borromeo, 2017). In Australasia, special needs dentistry is defined as: the branch of dentistry that is concerned with the oral health care of people with intellectual disability, medical, physical or psychiatric conditions that require special methods or techniques to prevent or treat oral health problems or where such conditions necessitate special dental treatment plans. (Dental Board of Australia, n.d.) Existence of this specialty is acknowledgement that individuals with complex medical problems are at greater risk of oral health concerns related to those problems, and often experience barriers to accessing timely and appropriate dental care. Having a professional role dedicated to the oral health needs of vulnerable patient and client groups provides an avenue for improved communication between the dental profession and other health disciplines; acknowledging shared objectives and enabling professional collaborations to ensure dental care provision is consistent with an individual’s unique health care needs. Within the dental profession itself, it also serves to educate oral health professionals about the importance of oral care for patients with complex medical problems and how treatment can be adapted to their needs. The collaboration of SLP, dietitians, and oral health professionals alongside individuals with dysphagia and their carers is essential in promoting good oral hygiene practices and mitigating risks associated with dysphagia. Each profession contributes unique expertise and perspectives in supporting an individual to maintain adequate nutrition and hydration while minimising the risk of aspiration and supporting quality of life. Table 1 offers a brief outline of the roles of each health professional in the support and management of an individual with dysphagia. Implementing effective oral care Due to the variety of protocols presented in the literature and the diversity of the aetiologies associated with dysphagia, there is no definitive oral care or oral hygiene regime that can be applied to all individuals with dysphagia. Rather, there are common guiding principles and procedures that can be adapted to the needs and situation of the individual and actively monitored and refined. Table 2 presents an overview of some considerations that would warrant a flexible, individualised approach to oral care provision. In Table 3, specific adaptations of oral care strategies for different degrees of dysphagia severity are presented. In the sections that follow, specific approaches and techniques to oral care that are suitable and recommended for three groups of patients with dysphagia are discussed: (a) patients receiving texture modified diets; (b) patients with profound dysphagia (or who are nil by mouth), and (c) patients who have sialorrhea (drooling). Oral care strategies for patients receiving texture modified diets Oral care for individuals receiving a texture modified diet has two objectives: (a) mechanically removing dental plaque and food debris, and (b) increasing factors protective against decay.

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JCPSLP Volume 20, Number 3 2018

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