JCPSLP Vol 20 No 3 November 2018

Table 1. Suggested roles of people involved in managing the oral care of individuals with dysphagia

People involved in oral care

Role in developing/ongoing management of oral care

Dietitian

• Provide advice to dentist about dietary modifications suggested for individual with dysphagia • Organise referral to dentist when concerned about compromised oral function due to potential dental problems • Review any concerns about diet raised by dentist • Advise dentist of any changes to diet management that may warrant review of oral hygiene plan • Reinforce agreed oral hygiene plan with individual with dysphagia and support recommendations of other health professionals • Provide advice to dentist about severity of dysphagia and management plan including feeding method, alterations to diet texture or fluid consistency, etc. • Identify any concerns with current oral care or ability to tolerate treatment with dentist • Explain importance of oral hygiene and make provisional suggestions regarding oral hygiene to be reviewed by dentist • Review recommendations made by dentist to ensure they are appropriate to patient and dysphagia status • Advise dentist of any changes to dysphagia status that may warrant review of oral hygiene plan • Reinforce agreed oral hygiene plan with individual with dysphagia and support recommendations of other health professionals • Complete oral assessment to determine presence of oral pathology and treatment need, and evaluate current oral hygiene • Make recommendations to individual and other health professionals involved in management regarding appropriate oral care • Introduce and demonstrate oral hygiene techniques to individual with dysphagia/carer • Review oral health and oral hygiene on regular basis

Speech-language pathologist

Dentist

Carer providing oral care (where applicable)

• Complete oral hygiene program as suggested by dentist • Organise review if concerned about patient’s tolerance of current oral hygiene regime • Organise relevant reviews for individual with dysphagia as suggested by health professionals

Table 2. Considerations when individualising oral hygiene recommendations for patients with dysphagia

Considerations at the level of the individual

Considerations at the level of the environment

• Patient’s current living arrangements/care facility • Current strategies used to support safe swallowing, e.g., positioning, adaptive strategies, compensatory strategies • Level of independence with activities of daily living, mobility • Adequacy of and adherence to current oral hygiene regime, if present • Patient’s degree of independence in performing and maintaining oral care • Patient’s level of motivation towards maintaining oral care

Mechanical cleansing Mechanical cleansing of the dentition is primarily achieved through toothbrushing. Many patients benefit from the use of electric toothbrushes to improve efficiency of cleaning. Brushing should be focused towards areas likely to accumulate plaque and food debris, such as around the gums and the fissures on the chewing surfaces of the teeth. The intention should be to clean all surfaces of all teeth and, where possible, the soft tissues. Brushing gently and using a toothbrush with a small head and soft bristles will prevent inadvertent trauma to the gums. Another site of plaque and food accumulation is often between the teeth. The difficulty of cleaning these areas is reduced as food becomes less fibrous. Although flossing is recommended where possible, the same result may be achieved using other interdental cleaning aids, such as interdental brushes (shown in Figure 1), which are often favoured by those unable to manage the • Patient’s medical status • Nature and degree of swallowing impairment (oral, pharyngeal, oesophageal dysphagia) • Oral vs. non-oral nutrition • Degree of diet modification (food and fluids) • Neurological deficits affecting oral musculature • Oral symptoms and their management, e.g., drooling, dry mouth • Dental status • Risk status for decay and periodontal disease • Concomitant conditions, e.g., physical disability, intellectual disability, complex communication needs, sensory impairment, challenging behaviours/behaviour of concern

level of manual dexterity required for flossing. Where concern exists about an individual’s ability to manage thin fluids, a damp toothbrush or interdental brush can be used. Similarly, if oral control is poor or there are postural or positioning concerns and/or the person does not have the ability to expectorate, a piece of gauze or oral swab (see Figure 2) can be used to rinse the mouth and remove debris. Mechanical cleaning of teeth is recommended at least twice daily for individuals maintaining any oral intake with completion after the final meal of the day the most crucial time. As aspiration risk increases, more frequent brushing is preferred; however, appropriate individualisation of strategies is likely to be required. It is often suggested that where meal supervision is recommended part of this supervision includes assistance in providing simple oral care after each meal to reduce both oral disease and aspiration of food remnants (Müller, 2014; van der Maarel-Wierink et al., 2013).

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JCPSLP Volume 20, Number 3 2018

Journal of Clinical Practice in Speech-Language Pathology