JCPSLP Vol 20 No 3 November 2018

Table 5. Summary of recommendations for patients with profound dysphagia who require assistance with oral hygiene

Posture

• For bedbound or immobile patients, the head and body should be raised to 30–45 degrees or the head tilted to one side when completing oral hygiene. • A small-headed or paediatric toothbrush should be used. • Electric or suction (aspirating) toothbrushes may be used where available. • Where no toothbrush is available, a piece of gauze wrapped around a finger may be used as an alternative to remove oral debris. • Cleaning should include all surfaces of the patient’s teeth, tongue, and hard palate. • Interdental brushes may be used to remove debris from between the teeth as a substitute for flossing. • Mechanical cleaning should ideally be completed for at least 1 minute 3 times a day after meals. Frequency of brushing should be individualised based on oral intake and risk status assessed by an oral health professional. • Following brushing, an oral swab should be used to remove debris from the mouth.

Mechanical debridement

• Where available, suction devices may also be used to remove debris. • Dentures should be removed at least daily for mechanical cleaning. • Toothpastes should always be fluoridated. • Toothpastes with reduced or no foaming agent are preferred.

Toothpaste

• The use of high fluoride toothpastes may be recommended by oral health professionals based on risk status. • The decision to not use a toothpaste due to concerns about swallowing should be made in consultation with an oral health professional such that supplementary measures can be implemented. • Where chlorhexidine is to be used, the mouthwash formulation may be applied using an oral swab. • Alcohol-free formulations should be used to prevent further drying of mucosa. • Gel formations may also be used with application to interdental brushes. • Moisturising ointment should be applied to the lips. Petroleum jelly should be avoided as it may dry out the oral mucosa further.

Use of other chemical agents

Post-oral care

& Hume, 2005). However, pooling of saliva, which is often indicative of impaired clearance rather than excess production, can result in an increased risk of decay and periodontal disease if coupled with stagnation of food (Bavikatte et al., 2012; Elman et al., 2005). What often presents as a greater concern to oral health professionals than drooling itself is the management of sialorrhea, as most medical interventions for this condition induce a saliva deficit. This produces symptoms and clinical manifestations of dry mouth (xerostomia) which significantly increases the risk of decay and fungal infection. There are many interventions for sialorrhea discussed in the literature ranging from: (a) surgery to remove, reduce or redirect the salivary glands, salivary ducts, or their parasymphathetic supply, (b) radiotherapy to the salivary glands, (c) botulinum toxin administered to the glands under ultrasound guidance, (d) use of anticholinergic and antimuscarinic agents, and (e) interventions aimed at enhancing posture and oromotor function (Bavikatte et al., 2012; Elman et al., 2005). From an oral health perspective, any irreversible intervention, such as surgery, is likely to have a deleterious effect on the dentition. Non-invasive interventions such addressing posture, improving oromotor function, and recommending oral swabbing are preferred by the dental team. Where surgical, radiotherapeutic, or pharmacological interventions are used, often SLPs and dentists are faced with helping a patient to manage significant changes in saliva production, specifically dry mouth and oral secretions that contain a higher mucin content (i.e., thick, ropy secretions) (Elman et al., 2005). Often mucolytic agents (e.g., grape juice) are recommended for consumption or for swabbing the oral cavity. This strategy may assist with patient comfort, but the acidic nature of these products can exacerbate risk of decay and acidic erosion, particularly in the absence of normal oral clearance and buffering systems provided by saliva.

Oral care strategies for patients with xerostomia should be based initially on the degree of dryness, the severity of dysphagia and the need for supplemental protective factors (e.g., high fluoride toothpastes) because of the significant shift towards an acidic environment. Higher fluoride toothpastes are an essential element of the oral hygiene routine for these patients and should routinely follow the use or ingestion of acidic agents so as to reduce damage to the dentition. In addition to targeted oral hygiene strategies, many patients may benefit from topical agents to address their dry mouth. These may range from increasing efforts to remain hydrated by frequently sipping water (if consistent with oro-phayrngeal swallowing ability and SLP recommendations) to using commercially available dry mouth products – see Table 6 for a list (Furness, Worthington, Bryan, Birchenough, & McMillan, 2011). Likewise, home remedies, such as bicarbonate soda mouth rinses, can assist in reducing acidity in the oral cavity. Where neuromuscular function does not enable the safe use of mouthwashes, these products, or simply water or olive oil, may be applied to the oral mucosal tissues through an atomiser spray bottle. Unfortunately, many of these strategies lack validation and instead are most successful when adapted by oral health professionals in conjunction with SLP and dietitian colleagues, to individual circumstances and preferences. Conclusions Regular and effective oral care improves comfort and quality of life and reduces the risk of adverse health sequelae associated with aspiration in individuals with dysphagia. An individualised, daily oral hygiene regime in conjunction with regular review by an oral health professional is considered best practice management in this population.

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JCPSLP Volume 20, Number 3 2018

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