JCPSLP Vol 20 No 3 November 2018

oral microorganisms, a factor that can be exacerbated by strategies for secretion management and polypharmacy (Scully & Felix, 2005). Periodontal disease can also cause bleeding gums resulting in an aversion to maintaining oral hygiene through regular oral care. In some cases, periodontal disease can result in teeth becoming loose and spontaneously falling out. Unfortunately, this increased oral burden further heightens risk of aspiration of plaque and debris in patients with profound dysphagia (Mody et al., 2007). Once significant calculus deposits are established, professional removal by a dentist or hygienist is necessary. Oral health professionals experienced in managing individuals with dysphagia will often use hand scalers and curettes rather than using conventional ultrasonic scalers with water spray. By doing so, these deposits are removed carefully with the instrument or gauze to reduce the risk of inadvertent swallowing or aspiration throughout the procedure. This may also have the benefit of increasing comfort for patients who already have swallowing difficulties. Regular oral hygiene for this group should be focused towards mechanical removal of plaque from the dentition and around the gums (van der Maarel-Wierink et al., 2013). This may be difficult to do with the brush itself and may be completed using an oral sponge swab or piece of gauze. Swabbing should be completed on both the buccal and lingual aspects of all upper and lower teeth as well as in the fornices of the buccal vestibule and sublingually. The procedure is recommended to be completed at least daily but with greater frequency preferred. As the literature suggests that these patients appear to be at lower risk of decay, it may be acceptable to not use toothpastes where SLPs are concerned about aspiration due to foaming agents. The use of toothpastes in these patients can, however, offer advantages to the person with dysphagia in the form of flavour, stimulation of saliva production to reduce oral dryness, and reduced halitosis. A summary of recommendations for patients with profound dysphagia requiring assistance with oral hygiene is provided in Table 5. Oral care strategies for patients with sialorrhea (drooling) and xerostomia (dry mouth) Sialorrhea, or drooling, can be a significant issue for individuals with dysphagia, increasing the risk of aspiration, associated feelings of embarrassment and discomfort, and social isolation (Bavikatte, Sit, & Hassoon, 2012; Elman, Dubin, Kelley, & McCluskey, 2005). From an oral health perspective, saliva itself does not present a problem and in many cases is considered protective of the dentition (Mount

should be sufficient for the whole mouth. Second, brushing can be completed with a damp toothbrush to remove plaque followed by a topical application of toothpaste smeared across the dentition. The lack of brushing following this application will prevent foaming. Other products, such as the GC Tooth Mousse range (GC Recaldent), have been designed for application in this manner. It is the current recommendation to expectorate the excess of these products rather than rinsing after their use. For individuals with dysphagia this recommendation should be maintained. Occasionally, the presence of significant periodontal disease or gingival inflammation may necessitate the use of products containing chlorhexidine. Often this is the result of an accumulation of food around or between the teeth causing gingival inflammation, or due to increased calculus deposits forming from reduced oral intake. Although it is conventionally recommended that chlorhexidine be used in mouthwash form, individuals with dysphagia may instead use gel forms which can be applied to the gums with interdental brushes. Alternatively, oral sponge swabs may be soaked in the mouthwash formulation, squeezed to get rid of excess, and used to swab the oral soft tissues. Use of chlorhexidine should follow recommendations from an oral health professional as the literature has reported minor adverse effects including brown staining of the dentition and taste alteration following prolonged use (Gürgan, Zaim, Bakirsoy, & Soykan, 2006; Strydonck, Slot, Velden, & Weijden, 2012). Oral care strategies for patients with profound dysphagia Profound dysphagia, or the inability to maintain adequate oral intake for nourishment or hydration, necessitates non-oral forms of nutrition. Although this is part of the continuum of management of dysphagia and may be familiar to SLPs, it presents a unique set of challenges for oral health professionals. Reduced oral intake may in some cases result in a reduction of nutritive sources for oral bacteria thereby reducing the risk of dental decay. However, this does not ameliorate the risk of gingival or periodontal disease. Mastication and fluid intake that usually disturb plaque deposits are absent when non-oral feeding is implemented, resulting in an increased build-up of calculus (tartar) and resultant periodontal disease (Mody, Maheshwari, Galecki, Kauffman, & Bradley, 2007). Breakage of these thick calculus deposits, most often present around the lower incisors, is often a concern of individuals who describe this as feeling like their “teeth chipping away”. Halitosis is also frequently reported due to oral dryness and stagnation of

Table 4. Toothpastes with increased fluoride content (> 1000ppm fluoride)

Toothpaste

Fluoride

Fluoride content

Surfactant

Biotène® Dry Mouth toothpaste

Sodium fluoride

1400ppm

CAPB

Colgate® NeutraFluor® 5000 Plus

Sodium Fluoride

5000ppm

SLS (reduced)

Colgate® Sensitive Pro-Relief™ range

Sodium monofluorophosphate

1450ppm

SLS

Oral-B® Pro-Health® range

Stannous fluoride Sodium fluoride

1450ppm

SLS

Pronamel® Daily Protection

Sodium fluoride

1450ppm

CAPB

Sensodyne® Repair and Protect

Sodium monofluororphosphate

1450ppm

CAPB

CAPB: cocaminodopropyl betaine; SLS: sodium laryl sulphate

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JCPSLP Volume 20, Number 3 2018

Journal of Clinical Practice in Speech-Language Pathology