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Dysphagia is the medical term for swallowing difficulties and has a number of causes.  It is most frequently seen in the elderly particularly with cognitive decline. Also in people who have conditions that have weakened or damaged the muscles and nerves used for swallowing such as 

• cerebral palsy,

• Parkinson’s disease,  

• head injury or stroke 

• Cancer of the head, neck, or esophagus may cause swallowing problems.

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 People with dysphagia are more susceptible to aspiration pneumonia, however, studies have shown dysphagia alone is generally not sufficient to cause pneumonia unless other risk factors are present such as poor oral hygiene due to aspirated material being heavily colonised with bacteria.(Langmore et al., 1998).

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Dysphagia in the presence of other risk factors such as poor oral health and dependency for oral care, is related to higher rates of aspiration pneumonia (Langmore et al, 1998)Consistent good oral hygiene has been shown to decrease the risk of aspiration pneumonia across several clinical settings ranging from residential aged-care facilities to neurologic intensive-care units (Fields, 2008; Hua et al., 2016; Juthani-Mehta et al., 2013; Watando et al., 2004).

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Realistic Oral Care Management of Individuals with Dysphagia 

When cleaning the mouth of someone with swallow difficulties extra care should be taken to reduce the risk of aspirating toothpaste or any debris that may be present in the mouth. Due to poor chewing and swallow function means that there is likely to be food stagnation in the oral cavity increasing the risk of dental decay leading to toothache and possible tooth loss.

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Oral Care Management for People with Dysphagia

When assisting someone with mouthcare who has poor swallow reflex, extra care should be taken to reduce the risk of aspirating toothpaste or any debris that may be present in the mouth.

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Mouthcare practice to consider

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• Place a towel around the chest area. If possible, sit person up to support safe swallowing position and lower the chin. 

• Complete an oral assessment to evaluate current oral hygiene status, any oral symptoms and their management eg. drooling, dry mouth.  This includes establishing someone's degree of independence in performing toothbrushing and their level of motivation to carry out their own mouthcare.

• If denture/s are worn, remove them.  Plaque bacteria will adhere to any hard surface therefore dentures need to be cleaned with a denture brush or toothbrush, mild soap and water. [see Denture Care Advice HERE]

• Attend to dry lips with balm 

• The use of a mouth prop for someone that has difficulty opening or clenches. Get the person to bite down on a second toothbrush to improve access to the whole mouth.

• Toothbrushing is recommended twice a day. Cleaning after the last meal of the day is most crucial. If meal supervision is required, simple oral care after each meal to reduce aspiration of food & oral disease.

• Depending on the ability to manage fluid, smear a small amount of non-foaming toothpaste onto a small, soft headed toothbrush or electric toothbrush.  If an electric toothbrush can be tolerated consider an Electric suction toothbrush. The led light helps for better vision and aspirating fluid provides more confidence with toothbrushing to this group. Alternatively, a manual aspirating toothbrush can be used if there is availability of a portable suction unit although most care facilities do not have this equipment.  Particularly beneficial for people with severe dysphagia or Nil by Mouth.

• Focus brushing areas where plaque and food are likely to accumulate such the biting surfaces and gum margins of the teeth. Angling the toothbrush at a 45 degrees along the margins of the teeth using a small back and forth motion unless you have been demonstrated by a dental professional otherwise. 

• Allow short breaks so that the person can rest encouraging the person to spit out if they are able to.  

• If you are able to - Remove plaque and debris from in-between the teeth with interdental brushes or flossettes as a toothbrush will not clean in-between.   

• If unable to spit, use a damp non fraying gauze to remove excess toothpaste and debris

• If the mouth is dry ensure it is kept as moist and comfortable mouth as possible with regular sips of water or lubricating with dry mouth products such as spray or gel. 

• If the mouth is particularly 'dirty' or you notice the gums are bleeding consider dipping the toothbrush in chlorhexidine mouthwash or gel and applying to the teeth and soft tissues.  Ensure you read the instructions as application of chlorhexidine and a dentifrice containing fluoride together is not as effective; they require to be used at separate intervals.

• Brush the tongue if coated with a soft toothbrush

• Review oral health and hygiene on a regular basis

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Removal of plaque from the teeth is achieve primarily through toothbrushing!

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How often should oral care be carried out?

• Routinely twice a day but as aspiration risk increases, more frequent brushing is preferred

• Where meal supervision is carried out, part of this supervision could include 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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Secretion Management

For people who have severely impaired swallow function, who are nil-by-mouth or at the end-of-life; this group often have very dry mouths which often result in the build up of dried saliva secretions on the soft tissues, commonly on the palate and tongue areas.  Removal of these secretions can be difficult as they are usually quite tenacious. 

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• Using a gloved finger apply water-based oral hydrating gel rub it into the soft tissues if you are able to otherwise apply the gel to Moutheze or 360 degree toothbrush. Allow the gel to soften the secretions for a couple of minutes before removing the secretions with a damp gauze, Moutheze or 360 degree toothbrush. Gently rub in a circular motion to loosen the secretions and remove with a damp gauze.

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Dry mouth management

Interestingly people often do not complain of a dry mouth but complain of difficulty chewing and swallowing. Due to the lack of saliva the teeth are more susceptible to problems such as decay, gum disease, thrush and ulcers. 

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Saliva has many roles which help keep the mouth healthy. 

It contains:

• enzymes and antigens to protect against bacteria. 

• calcium and other minerals which help repair tooth enamel

• helps to keep dentures more securely in place

• lubricates the mouth helping with swallowing and talking

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Unfortunately dry mouth products are not in the mouth for long before it requires to be reapplied, therefore keeping the mouth hydrated with regular sips of water is recommended if someone is able to.  Where this is not possible a dry mouth spray can be used or apply water-based hydrating gel for dry mouth with a gloved finger or MC3 stick, 360 toothbrush;  Gels are especially helpful before sleep at night as it helps reduce waking up in the night with a dry mouth.

 

Organise referral to dentist when concerned about compromised oral function due to potential dental problems