JCPSLP Vol 20 No 3 November 2018

Table 3. Oral hygiene recommendations based on dysphagia severity and common speech-language pathology interventions.

Dysphagia severity* Explanation and SLP interventions

Oral hygiene recommendations

1. Minimal dysphagia Slight deviance from normal swallow on videofluoroscopy Patient reports change in sensation during swallow No change in diet

Normal oral hygiene – i.e., twice daily toothbrushing with fluoridated toothpaste

2. Mild dysphagia

Dysphagia managed by specific swallow techniques Slightly modified diet Potential for aspiration exists Diminished by specific swallow techniques and modified diet Eating time significantly increased Supplemental nutrition may be indicated Significant potential for aspiration Trace aspiration of one or more consistencies on videofluoroscopy Specific techniques implemented to minimise aspiration Supervision during mealtimes May require supplemental nutrition orally or via feeding tube Aspirates 5–10% on one or more consistencies Cough reflex absent or non-protective Alternative mode of feeding required, nil by mouth may be indicated

Toothbrushing: with high fluoride or low foaming toothpaste Interdental cleaning: flossing, interdental brushes Frequency: at least twice daily

3. Mild-moderate dysphagia

4. Moderate dysphagia

Toothbrushing: with high fluoride or low foaming toothpaste Frequency: after each meal If unable to tolerate foaming of toothpaste, follow measures for severe dysphagia

5. Moderately severe dysphagia

Toothbrushing: dry/damp, no toothpaste Topical application of fluoride product with swabbing to remove excess Frequency: at 1–2 times daily

6. Severe dysphagia More than 10% aspiration for all consistencies Nil by mouth recommended

*Dysphagia severity ratings based on classification developed by Waxman et al. (1990)

Reducing risk factors of dental decay Mechanical cleansing should be supplemented with proactive efforts to reduce the risk of decay by promoting remineralisation of tooth structure. Conventionally, dentists discuss hydration, dietary modifications, and other lifestyle factors in addition to oral hygiene measures (Mount & Hume, 2005). Those experienced in the management of individuals with complex medical issues recognise that the possibility of making changes to many of these factors is not always realistic. One measure that is possible for individuals with dysphagia, however, is adapting the oral hygiene products used to increase the resistance of tooth enamel to demineralisation (Mount & Hume, 2005). As a result, where the dietary texture or fluid consistency is modified, individuals with dysphagia should be encouraged to use toothpastes with a higher fluoride content (i.e., greater than 1000ppm of fluoride). Incorporating fluoride into the enamel crystal structure of the teeth reduces the critical pH at which dissolution occurs, thereby increasing its resistance to demineralisation

from plaque acids (Mount & Hume, 2005). There are a range of higher strength toothpastes available, some of which are listed in Table 4. Many of these have the added benefit of either reduced or no sodium lauryl sulphate (SLS) content, a common foaming agent. It is important to recognise, however, that the absence of SLS does not mean that the toothpaste does not contain an alternative foaming agent. Several products do not contain SLS but instead contain cocamidopropyl betaine (CAPB). Other than anecdotal reports to suggest that CAPB may produce less foaming that SLS, there is little evidence in the literature or from manufacturers to quantify surfactant content or the relative impact on foaming. Natural toothpastes are not recommended because the absence of fluoride provides no benefit to the dentition and the abrasiveness of other ingredients can, in fact, damage the tooth surface. Where concerns exist about the use of foaming toothpastes, there are several adaptations that may be appropriate for individuals with dysphagia. First, the amount of toothpaste used should be reduced to just a smear which

Figure 1. Interdental brushes

Figure 2. Oral swab

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JCPSLP Volume 20, Number 3 2018

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