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Basic oral care for patients with dysphagia - A Special Needs Dentistry
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 Nutrition, swallowing, mealtimes: Recipes for success

Basic oral care for

patients with dysphagia
A Special Needs Dentistry perspective
Mathew Albert Wei Ting Lim

KEYWORDS Oral health is known to be a factor contributing (Mount & Hume, 2005). Stagnation of food in the oral cavity
to health-related quality of life in the general increases risk of dental decay; however, this is exacerbated
ASPIRATION by nutritional fortification of foods. Increased carbohydrate
PNEUMONIA population. However, it is particularly
content or the use of starches or simple carbohydrates
DENTISTRY
important for the health and outcomes of to thicken fluids (frequently granulated maize starch
people with dysphagia, especially those at [maltodextrin] or gums [xantham]) are highly cariogenic
DYSPHAGIA
risk of aspiration. Despite poor oral hygiene and can hasten and accentuate demineralisation of the
ORAL HEALTH tooth surface (Mount & Hume, 2005; O’Leary, Hanson, &
being considered a modifiable risk factor, oral
ORAL HYGIENE health professionals such as specialists in Smith, 2010). Prolonged accumulation of plaque may also
predispose patients to gum (periodontal) disease.
special needs dentistry may have limited
THIS ARTICLE involvement in the multidisciplinary care of Oral health and dysphagia
HAS BEEN individuals with dysphagia. This article offers The importance of oral health in contributing to overall
PEER- a special needs dentistry perspective on the systemic health is often overlooked. Research in recent
REVIEWED considerations and approaches to oral care years has highlighted the importance of optimal oral care in
for people with dysphagia. Several techniques mitigating the problems associated with dysphagia,
particularly individuals at risk of aspiration (Eisenstadt,
often used by specialists in this field, ranging
2010; Langmore et al., 1998; Martin et al., 1994). Aspiration
from oral hygiene protocols to dental treatment, occurs when foreign material, including food debris, saliva,
will be discussed. Strategies for daily oral and plaque, descends into the bronchial tree and lung
hygiene regimes, which can be easily adapted alveoli (Müller, 2014; Scannapieco & Mylotte, 1996).
and individualised by carers, support workers, Aspiration pneumonia is a serious complication of this
nursing and allied health professionals in the process. Aspiration pneumonia has been reported to be a
leading cause of death and hospitalisation among residents
absence of oral health practitioners, are
Mathew Albert in nursing homes and the underlying cause of just under
Wei Ting Lim presented. Ultimately, however, this article 1% of all Australian deaths (Australian Bureau of Statistics,
aims to facilitate discussion and promote 2014; Terpenning, 2005).
increased collaboration between speech- Dysphagia is a recognised a risk factor for aspiration
language pathologists and oral health pneumonia, however, studies have shown that it alone
is generally not sufficient to cause pneumonia unless
professionals in the management of
other risk factors are also present (Langmore et al., 1998).
individuals with dysphagia. Such risk factors include poor oral hygiene, periodontal

I
n addition to playing an important role in mastication, disease, untreated dental disease, and nocturnal denture
a person’s dentition can also be central to self- wearing (Müller, 2014). Oral plaque has been identified as
image and contribute to quality of life. Unfortunately, a potentially modifiable risk factor in 10.3% of pneumonias
many approaches used in the management of oral requiring hospitalisation in community-dwelling older
and pharyngeal dysphagia can place the oral cavity at adults (Juthani-Mehta et al., 2013). Likewise, nocturnal
greater risk of disease. For example, dietary modification denture wearing, which due to the associated increase
techniques (such as alteration of food texture or in oral microbial burden, has been found to present a
thickening of fluid) used to alter bolus or liquid flow and comparable risk of developing pneumonia as a history of
compensate for compromised swallowing function, can swallowing difficulties, stroke, or respiratory disease (Iinuma
increase oral retention and in doing so facilitate growth et al., 2014). Oral hygiene is therefore a critical element of
of oral microorganisms that lead to dental decay. Dental preventing serious sequelae.
decay (caries) occurs because of a dynamic, complex,
and multifactorial process that arises from the continual Oral hygiene
loss of mineral ions from the tooth surface. One of the Maintenance of good oral hygiene has been shown to
most significant risk factors leading to this process is decrease the risk of aspiration pneumonia across several
the production of acids by microorganisms in the plaque clinical settings ranging from residential aged-care facilities

142 JCPSLP Volume 20, Number 3 2018 Journal of Clinical Practice in Speech-Language Pathology
to neurologic intensive-care units (Fields, 2008; Hua et al., overall well-being and quality of life, specialised oral health
2016; Juthani-Mehta et al., 2013; Watando et al., 2004). care for many individuals, including those with dysphagia, is
The Centers for Disease Control and Prevention often separate from their multidisciplinary management or is
recommend that a comprehensive oral hygiene program conducted by members of other professions such as
should be developed and implemented for all patients being nursing or speech-language pathology (SLP).
treated in an acute care setting and residents of long-term Special Needs Dentistry (SND) as a dental specialty
care facilities with the aim of reducing the risk of pneumonia was established in 2003 with the aim to assist in bridging
(Tablan, Anderson, Besser, Bridges, & Hajjeh, 2004). Similar the gap between dentists and other health professionals
recommendations in Australia, particularly within the (Chalmers, 2004; Lim & Borromeo, 2017). In Australasia,
aged-care setting, were advocated for and remain the special needs dentistry is defined as:
legacy of the late Jane Chalmers (Chalmers, 2003; Fricker the branch of dentistry that is concerned with the oral
& Lewis, 2009). In addition to preventing and modulating health care of people with intellectual disability, medical,
the microbial colonisation of the oropharynx, evidence physical or psychiatric conditions that require special
suggests that oral hygiene may increase cough reflex methods or techniques to prevent or treat oral health
sensitivity and thus reduce the risk of aspiration (Tablan et problems or where such conditions necessitate special
al., 2004; Watando et al., 2004). dental treatment plans. (Dental Board of Australia, n.d.)
Studies of the nature and effectiveness of oral hygiene Existence of this specialty is acknowledgement that
interventions have largely investigated three areas: (a) individuals with complex medical problems are at greater
mechanical cleaning of the dentition, (b) the use of risk of oral health concerns related to those problems, and
chemical agents, and (c) assistance or professional oral often experience barriers to accessing timely and
care. Mechanical removal of plaque and food debris appropriate dental care. Having a professional role
from the dentition and prostheses has consistently been dedicated to the oral health needs of vulnerable patient and
found to reduce pneumonia risk (van der Maarel-Wierink, client groups provides an avenue for improved
Vanobbergen, Bronkhorst, Schols, & de Baat, 2013). communication between the dental profession and other
The effectiveness of using chemical agents, such as health disciplines; acknowledging shared objectives and
chlorhexidine, has shown more variable outcomes with enabling professional collaborations to ensure dental care
greatest efficacy noted in patients who are ventilator- provision is consistent with an individual’s unique health
dependent or receiving non-oral feeding (Hua et al., 2016; care needs. Within the dental profession itself, it also serves
Müller, 2014). Provision of oral hygiene assistance by either to educate oral health professionals about the importance
a trained carer or oral health professional, at least weekly, of oral care for patients with complex medical problems and
has been consistently shown to reduce oral microbial how treatment can be adapted to their needs.
burden and risk of pneumonia (Sjögren, Nilsson, Forsell, The collaboration of SLP, dietitians, and oral health
Johansson, & Hoogstraate, 2008). professionals alongside individuals with dysphagia and their
Despite strong evidence supporting the importance of carers is essential in promoting good oral hygiene practices
promoting and maintaining oral hygiene, insufficient data and mitigating risks associated with dysphagia. Each
exists regarding the relative effectiveness of strategies that profession contributes unique expertise and perspectives
aim to either manage swallowing problems or address in supporting an individual to maintain adequate nutrition
oral hygiene (Loeb, Becker, Eady, & Walker-Dilks, 2003). and hydration while minimising the risk of aspiration and
Given the diverse aetiologies that may result in swallowing supporting quality of life. Table 1 offers a brief outline of
difficulties, it is unlikely that a single management strategy the roles of each health professional in the support and
is likely to be effective; rather a multidimensional and management of an individual with dysphagia.
multidisciplinary approach may better address all salient
factors. Multidisciplinary collaboration encourages greater Implementing effective oral care
communication between professionals, person-centred Due to the variety of protocols presented in the literature
problem solving, potentially more efficient and effective use and the diversity of the aetiologies associated with
of resources, enhanced client outcomes and increased dysphagia, there is no definitive oral care or oral hygiene
client satisfaction (Epstein, 2014). regime that can be applied to all individuals with dysphagia.
Rather, there are common guiding principles and
Multidisciplinary collaboration procedures that can be adapted to the needs and situation
and the role of the specialist in of the individual and actively monitored and refined. Table 2
presents an overview of some considerations that would
special needs dentistry warrant a flexible, individualised approach to oral care
Across a range of settings, people with dysphagia should provision. In Table 3, specific adaptations of oral care
benefit from access to the collective expertise of a team of strategies for different degrees of dysphagia severity are
health professionals and a coordinated approach to care presented. In the sections that follow, specific approaches
(Jessup, 2007; Wagner, 2000). However, the involvement of and techniques to oral care that are suitable and
oral health professionals, such as specialists in special recommended for three groups of patients with dysphagia
needs dentistry, in the management of individuals with are discussed: (a) patients receiving texture modified diets;
dysphagia has been limited (Lim & Borromeo, 2017). The (b) patients with profound dysphagia (or who are nil by
reasons for this may be reflective of the lack of integration mouth), and (c) patients who have sialorrhea (drooling).
of dental services into general health care in the Australian
health system, the historical separation of medicine and Oral care strategies for patients receiving
dentistry in many parts of the world, the lack of interest and texture modified diets
advocacy on the part of oral health professionals, or the Oral care for individuals receiving a texture modified diet
perception that dentists would be unlikely to make a valuable has two objectives: (a) mechanically removing dental plaque
contribution in this area of practice. Despite growing and food debris, and (b) increasing factors protective
evidence to support the importance of good oral health to against decay.

www.speechpathologyaustralia.org.au JCPSLP Volume 20, Number 3 2018 143

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

People involved in oral Role in developing/ongoing management of oral care

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

Speech-language • Provide advice to dentist about severity of dysphagia and management plan including feeding method, alterations
pathologist 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

Dentist • 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

Carer providing oral care • Complete oral hygiene program as suggested by dentist
(where applicable) • 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 medical status • Patient’s current living arrangements/care facility

• Nature and degree of swallowing impairment (oral, pharyngeal, • Current strategies used to support safe swallowing, e.g., positioning,
oesophageal dysphagia) adaptive strategies, compensatory strategies
• Oral vs. non-oral nutrition • Level of independence with activities of daily living, mobility
• Degree of diet modification (food and fluids) • Adequacy of and adherence to current oral hygiene regime, if
• Neurological deficits affecting oral musculature present
• Oral symptoms and their management, e.g., drooling, dry mouth • Patient’s degree of independence in performing and maintaining
• Dental status oral care
• Risk status for decay and periodontal disease • Patient’s level of motivation towards maintaining oral care
• Concomitant conditions, e.g., physical disability, intellectual
disability, complex communication needs, sensory impairment,
challenging behaviours/behaviour of concern

Mechanical cleansing level of manual dexterity required for flossing. Where

Mechanical cleansing of the dentition is primarily achieved concern exists about an individual’s ability to manage thin
through toothbrushing. Many patients benefit from the use fluids, a damp toothbrush or interdental brush can be used.
of electric toothbrushes to improve efficiency of cleaning. Similarly, if oral control is poor or there are postural or
Brushing should be focused towards areas likely to positioning concerns and/or the person does not have the
accumulate plaque and food debris, such as around the ability to expectorate, a piece of gauze or oral swab (see
gums and the fissures on the chewing surfaces of the teeth. Figure 2) can be used to rinse the mouth and remove debris.
The intention should be to clean all surfaces of all teeth and, Mechanical cleaning of teeth is recommended at least
where possible, the soft tissues. Brushing gently and using twice daily for individuals maintaining any oral intake with
a toothbrush with a small head and soft bristles will prevent completion after the final meal of the day the most crucial
inadvertent trauma to the gums. Another site of plaque and time. As aspiration risk increases, more frequent brushing is
food accumulation is often between the teeth. The difficulty preferred; however, appropriate individualisation of strategies
of cleaning these areas is reduced as food becomes less is likely to be required. It is often suggested that where
fibrous. Although flossing is recommended where possible, meal supervision is recommended part of this supervision
the same result may be achieved using other interdental includes assistance in providing simple oral care after each
cleaning aids, such as interdental brushes (shown in Figure meal to reduce both oral disease and aspiration of food
1), which are often favoured by those unable to manage the remnants (Müller, 2014; van der Maarel-Wierink et al., 2013).

144 JCPSLP Volume 20, Number 3 2018 Journal of Clinical Practice in Speech-Language Pathology
 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

Normal oral hygiene – i.e., twice daily toothbrushing
Patient reports change in sensation during swallow
with fluoridated toothpaste
No change in diet

2. Mild dysphagia Dysphagia managed by specific swallow techniques

Slightly modified diet Toothbrushing: with high fluoride or low foaming
3. Mild-moderate Potential for aspiration exists toothpaste
dysphagia Diminished by specific swallow techniques and modified diet Interdental cleaning: flossing, interdental brushes
Eating time significantly increased Frequency: at least twice daily
Supplemental nutrition may be indicated

4. Moderate Significant potential for aspiration

dysphagia Toothbrushing: with high fluoride or low foaming
Trace aspiration of one or more consistencies on
toothpaste
videofluoroscopy
Frequency: after each meal
Specific techniques implemented to minimise aspiration
If unable to tolerate foaming of toothpaste, follow
Supervision during mealtimes
measures for severe dysphagia
May require supplemental nutrition orally or via feeding tube

5. Moderately severe Aspirates 5–10% on one or more consistencies

dysphagia Cough reflex absent or non-protective Toothbrushing: dry/damp, no toothpaste
Alternative mode of feeding required, nil by mouth may be Topical application of fluoride product with swabbing
indicated to remove excess
6. Severe dysphagia More than 10% aspiration for all consistencies Frequency: at 1–2 times daily
Nil by mouth recommended

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

Reducing risk factors of dental decay from plaque acids (Mount & Hume, 2005). There are a
Mechanical cleansing should be supplemented with range of higher strength toothpastes available, some of
proactive efforts to reduce the risk of decay by promoting which are listed in Table 4. Many of these have the added
remineralisation of tooth structure. Conventionally, dentists benefit of either reduced or no sodium lauryl sulphate
discuss hydration, dietary modifications, and other lifestyle (SLS) content, a common foaming agent. It is important
factors in addition to oral hygiene measures (Mount & to recognise, however, that the absence of SLS does not
Hume, 2005). Those experienced in the management of mean that the toothpaste does not contain an alternative
individuals with complex medical issues recognise that the foaming agent. Several products do not contain SLS but
possibility of making changes to many of these factors is instead contain cocamidopropyl betaine (CAPB). Other than
not always realistic. One measure that is possible for anecdotal reports to suggest that CAPB may produce less
individuals with dysphagia, however, is adapting the oral foaming that SLS, there is little evidence in the literature or
hygiene products used to increase the resistance of tooth from manufacturers to quantify surfactant content or the
enamel to demineralisation (Mount & Hume, 2005). As a relative impact on foaming. Natural toothpastes are not
result, where the dietary texture or fluid consistency is recommended because the absence of fluoride provides
modified, individuals with dysphagia should be encouraged no benefit to the dentition and the abrasiveness of other
to use toothpastes with a higher fluoride content (i.e., ingredients can, in fact, damage the tooth surface.
greater than 1000ppm of fluoride). Where concerns exist about the use of foaming
Incorporating fluoride into the enamel crystal structure toothpastes, there are several adaptations that may be
of the teeth reduces the critical pH at which dissolution appropriate for individuals with dysphagia. First, the amount
occurs, thereby increasing its resistance to demineralisation of toothpaste used should be reduced to just a smear which

Figure 1. Interdental brushes Figure 2. Oral swab

www.speechpathologyaustralia.org.au JCPSLP Volume 20, Number 3 2018 145

 should be sufficient for the whole mouth. Second, brushing oral microorganisms, a factor that can be exacerbated by
can be completed with a damp toothbrush to remove plaque strategies for secretion management and polypharmacy
followed by a topical application of toothpaste smeared (Scully & Felix, 2005). Periodontal disease can also cause
across the dentition. The lack of brushing following this bleeding gums resulting in an aversion to maintaining
application will prevent foaming. Other products, such as oral hygiene through regular oral care. In some cases,
the GC Tooth Mousse range (GC Recaldent), have been periodontal disease can result in teeth becoming loose and
designed for application in this manner. It is the current spontaneously falling out. Unfortunately, this increased oral
recommendation to expectorate the excess of these burden further heightens risk of aspiration of plaque and
products rather than rinsing after their use. For individuals debris in patients with profound dysphagia (Mody et al.,
with dysphagia this recommendation should be maintained. 2007).
Occasionally, the presence of significant periodontal Once significant calculus deposits are established,
disease or gingival inflammation may necessitate the use of professional removal by a dentist or hygienist is necessary.
products containing chlorhexidine. Often this is the result Oral health professionals experienced in managing
of an accumulation of food around or between the teeth individuals with dysphagia will often use hand scalers and
causing gingival inflammation, or due to increased calculus curettes rather than using conventional ultrasonic scalers
deposits forming from reduced oral intake. Although it is with water spray. By doing so, these deposits are removed
conventionally recommended that chlorhexidine be used in carefully with the instrument or gauze to reduce the risk
mouthwash form, individuals with dysphagia may instead of inadvertent swallowing or aspiration throughout the
use gel forms which can be applied to the gums with procedure. This may also have the benefit of increasing
interdental brushes. Alternatively, oral sponge swabs may comfort for patients who already have swallowing
be soaked in the mouthwash formulation, squeezed to get difficulties.
rid of excess, and used to swab the oral soft tissues. Use Regular oral hygiene for this group should be focused
of chlorhexidine should follow recommendations from an towards mechanical removal of plaque from the dentition
oral health professional as the literature has reported minor and around the gums (van der Maarel-Wierink et al., 2013).
adverse effects including brown staining of the dentition This may be difficult to do with the brush itself and may be
and taste alteration following prolonged use (Gürgan, Zaim, completed using an oral sponge swab or piece of gauze.
Bakirsoy, & Soykan, 2006; Strydonck, Slot, Velden, & Swabbing should be completed on both the buccal and
Weijden, 2012). lingual aspects of all upper and lower teeth as well as in
the fornices of the buccal vestibule and sublingually. The
Oral care strategies for patients with procedure is recommended to be completed at least daily
profound dysphagia but with greater frequency preferred. As the literature
Profound dysphagia, or the inability to maintain adequate suggests that these patients appear to be at lower risk of
oral intake for nourishment or hydration, necessitates decay, it may be acceptable to not use toothpastes where
non-oral forms of nutrition. Although this is part of the SLPs are concerned about aspiration due to foaming
continuum of management of dysphagia and may be agents. The use of toothpastes in these patients can,
familiar to SLPs, it presents a unique set of challenges for however, offer advantages to the person with dysphagia
oral health professionals. in the form of flavour, stimulation of saliva production to
Reduced oral intake may in some cases result in a reduce oral dryness, and reduced halitosis. A summary of
reduction of nutritive sources for oral bacteria thereby recommendations for patients with profound dysphagia
reducing the risk of dental decay. However, this does requiring assistance with oral hygiene is provided in Table 5.
not ameliorate the risk of gingival or periodontal disease.
Mastication and fluid intake that usually disturb plaque Oral care strategies for patients with sialorrhea
deposits are absent when non-oral feeding is implemented, (drooling) and xerostomia (dry mouth)
resulting in an increased build-up of calculus (tartar) and Sialorrhea, or drooling, can be a significant issue for
resultant periodontal disease (Mody, Maheshwari, Galecki, individuals with dysphagia, increasing the risk of aspiration,
Kauffman, & Bradley, 2007). Breakage of these thick associated feelings of embarrassment and discomfort, and
calculus deposits, most often present around the lower social isolation (Bavikatte, Sit, & Hassoon, 2012; Elman,
incisors, is often a concern of individuals who describe this Dubin, Kelley, & McCluskey, 2005). From an oral health
as feeling like their “teeth chipping away”. Halitosis is also perspective, saliva itself does not present a problem and in
frequently reported due to oral dryness and stagnation of many cases is considered protective of the dentition (Mount

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 1450ppm SLS

Sodium fluoride

Pronamel® Daily Protection Sodium fluoride 1450ppm CAPB

Sensodyne® Repair and Protect Sodium monofluororphosphate 1450ppm CAPB

CAPB: cocaminodopropyl betaine; SLS: sodium laryl sulphate

146 JCPSLP Volume 20, Number 3 2018 Journal of Clinical Practice in Speech-Language Pathology
 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.

Mechanical • A small-headed or paediatric toothbrush should be used.

debridement • 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.
• Where available, suction devices may also be used to remove debris.
• Dentures should be removed at least daily for mechanical cleaning.

Toothpaste • Toothpastes should always be fluoridated.

• Toothpastes with reduced or no foaming agent are preferred.
• 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.

Use of other • Where chlorhexidine is to be used, the mouthwash formulation may be applied using an oral swab.
chemical agents • Alcohol-free formulations should be used to prevent further drying of mucosa.
• Gel formations may also be used with application to interdental brushes.

Post-oral care • Moisturising ointment should be applied to the lips. Petroleum jelly should be avoided as it may dry out the oral
mucosa further.

& Hume, 2005). However, pooling of saliva, which is often Oral care strategies for patients with xerostomia should
indicative of impaired clearance rather than excess be based initially on the degree of dryness, the severity of
production, can result in an increased risk of decay and dysphagia and the need for supplemental protective factors
periodontal disease if coupled with stagnation of food (e.g., high fluoride toothpastes) because of the significant
(Bavikatte et al., 2012; Elman et al., 2005). shift towards an acidic environment. Higher fluoride
What often presents as a greater concern to oral health toothpastes are an essential element of the oral hygiene
professionals than drooling itself is the management of routine for these patients and should routinely follow the
sialorrhea, as most medical interventions for this condition use or ingestion of acidic agents so as to reduce damage
induce a saliva deficit. This produces symptoms and clinical to the dentition.
manifestations of dry mouth (xerostomia) which significantly In addition to targeted oral hygiene strategies, many
increases the risk of decay and fungal infection. There are patients may benefit from topical agents to address
many interventions for sialorrhea discussed in the literature their dry mouth. These may range from increasing
ranging from: (a) surgery to remove, reduce or redirect the efforts to remain hydrated by frequently sipping water
salivary glands, salivary ducts, or their parasymphathetic (if consistent with oro-phayrngeal swallowing ability and
supply, (b) radiotherapy to the salivary glands, (c) botulinum SLP recommendations) to using commercially available
toxin administered to the glands under ultrasound guidance, dry mouth products – see Table 6 for a list (Furness,
(d) use of anticholinergic and antimuscarinic agents, and Worthington, Bryan, Birchenough, & McMillan, 2011).
(e) interventions aimed at enhancing posture and oromotor Likewise, home remedies, such as bicarbonate soda mouth
function (Bavikatte et al., 2012; Elman et al., 2005). From rinses, can assist in reducing acidity in the oral cavity.
an oral health perspective, any irreversible intervention, Where neuromuscular function does not enable the safe
such as surgery, is likely to have a deleterious effect on use of mouthwashes, these products, or simply water
the dentition. Non-invasive interventions such addressing or olive oil, may be applied to the oral mucosal tissues
posture, improving oromotor function, and recommending through an atomiser spray bottle. Unfortunately, many
oral swabbing are preferred by the dental team. of these strategies lack validation and instead are most
Where surgical, radiotherapeutic, or pharmacological successful when adapted by oral health professionals in
interventions are used, often SLPs and dentists are faced conjunction with SLP and dietitian colleagues, to individual
with helping a patient to manage significant changes in circumstances and preferences.
saliva production, specifically dry mouth and oral secretions
that contain a higher mucin content (i.e., thick, ropy Conclusions
secretions) (Elman et al., 2005). Often mucolytic agents Regular and effective oral care improves comfort and
(e.g., grape juice) are recommended for consumption or quality of life and reduces the risk of adverse health
for swabbing the oral cavity. This strategy may assist with sequelae associated with aspiration in individuals with
patient comfort, but the acidic nature of these products can dysphagia. An individualised, daily oral hygiene regime in
exacerbate risk of decay and acidic erosion, particularly in conjunction with regular review by an oral health
the absence of normal oral clearance and buffering systems professional is considered best practice management in
provided by saliva. this population.

www.speechpathologyaustralia.org.au JCPSLP Volume 20, Number 3 2018 147

 Table 6. Dry mouth products aimed at relief of dry mouth symptoms

Product Instructions for use Action of therapy

Biotène® Moisturising Mouth Spray Spray onto oral soft tissues as required Lubricant

Biotène® Dry Mouth Mouthwash Rinse mouth with mouthwash to relieve oral Lubricant
dryness

Biotène® Oral Balance Moisturising Gel Apply gel to oral soft tissues and teeth for relief of Lubricant
dryness. May be used under dentures to improve
retention and dryness.

Colgate® Dry Mouth Relief Fluoride Rinse mouth with mouthwash for relief of oral Coats oral tissues
Mouthwash dryness as required Lubricant
Fluoride content to reduce risk of decay

Denta-Med Gel Apply to oral tissues for relief of dry mouth Mucoadhesive gel
symptoms. Lubricant
Saliva substitute

GC® Dry Mouth Gel Smear gel over surfaces of teeth and mouth Lubricant
tissues. May be applied as required throughout the Stimulates salivary flow
day and at night after normal oral hygiene.

Hamilton® Aquae® Dry Mouth Gel Apply gel to oral tissues for relief of oral dryness. Supplements normal saliva
Lubricant

Hamilton® Aquae® Dry Mouth Spray Spray on oral tissues for relief of oral dryness. Supplements normal saliva
Lubricant

OraCoat XyliMelts® for dry mouth Stick XyliMelts® disc to outside of molar, gums, Moisturises mouth
or dentures. Stimulating salivary flow

Oral7® Moisturising Mouthwash Rinse with mouthwash for relief of oral dryness. Contains enzymes to substitute normal saliva
Lubricant

Oral7® Moisturising Toothpaste Complete normal toothbrushing with toothpaste. Contains enzymes to substitute normal saliva
No SLS to reduce irritation

Oral7® Moisturising Mouth Gel Apply to teeth and oral soft tissues for relief of dry Contains natural enzymes to reinforce
mouth symptoms. functions of healthy saliva
Soothes and protect gums

Dental interventions provided to individuals with to increase awareness about the issues experienced by
dysphagia can be complementary to and consistent with individuals with dysphagia within the oral health profession
the goals of treatment developed by speech-language to promote shared knowledge and achieve the best
pathologists. Minor adaptations to the way conventional outcomes for patients.
dental treatment is provided can assist individuals with
swallowing difficulties to comfortably receive the oral and References
dental treatment they require. Many daily oral hygiene Australian Bureau of Statistics. (2014). Diseases of the
strategies are relatively simple to institute and can be respiratory system (J00-J99). 3303.0 Causes of death,
adapted to the needs of an individual following a detailed Australia, 2011. Retrieved from http://www.abs.gov.au/
assessment by an oral health professional and careful and ausstats/[email protected]/Lookup/D52CC9949E64E0EFCA257B2
systematic consideration of a range of factors. Special E000D74DA?opendocument
Bavikatte, G., Sit, P. L., & Hassoon, A. (2012).
Needs Dentistry remains a small and slowly growing dental
Management of drooling of saliva. British Journal of Medical
specialty, but those involved are dedicated to increasing
Practitioners, 5(1), a507.
communication and collaboration between our professions
Chalmers, J. M. (2004). A new era of oral health
to ensure individuals with dysphagia, as well as those with
promotion for special needs dentistry. Special Care in
other significant medical issues and impairments, continue
Dentistry, 24(4), 217–219.
to receive the best health outcomes possible. There is Chalmers, J. M. (2003). Oral health promotion for our ageing
potential not only for greater interprofessional collaboration Australian population. Australian Dental Journal, 48(1), 2–9.
between SLPs and oral health practitioners, but also for Dental Board of Australia. (n.d.) List of specialties.
ongoing learning and development opportunities. Retrieved from www.dentalboard.gov.au/.../default.aspx?re
Specialists in special needs dentistry continue to cord=WD10%2F3238&dbid=AP&chksum=hXwmbYjUdcXv
advocate for the oral health needs of individuals with 23v2lFcC3w%3D%3D
dysphagia and hope to foster greater communication and Eisenstadt, E. S. (2010). Dysphagia and aspiration
collaboration between the dental profession and other pneumonia in older adults. Journal of the American
health professions. Similarly, specialists in this field continue Association of Nurse Practitioners, 22(1), 17–22.

148 JCPSLP Volume 20, Number 3 2018 Journal of Clinical Practice in Speech-Language Pathology
 Elman, L. B., Dubin, R. M., Kelley, M., & McCluskey, group. Journal of the American Geriatrics Society, 55(12),
L. (2005). Management of oropharyngeal and 1921–1926.
tracheobronchial secretions in patients with neurologic Mount, G. J., & Hume, W. (2005). Preservation and
disease. Journal of Palliative Medicine, 8(6), 1150–1159. restoration of tooth structure (2nd ed.). Sandgate
Epstein, N. E. (2014). Multidisciplinary in-hospital Queensland, Australia: Knowledge Books and Software.
teams improve patient outcomes: A review. Surgical Müller, F. (2014). Oral hygiene reduces the mortality
Neurology International, 5(Suppl 7), S295–S303. http://doi. from aspiration pneumonia in frail elders. Journal of Dental
org/10.4103/2152-7806.139612 Research, 94(3 suppl), 14S–16S.
Fields, L. B. (2008). Oral care intervention to reduce O’Leary, M., Hanson, B., & Smith, C. (2010). Viscosity
incidence of ventilator-associated pneumonia in the and non-Newtonian features of thickened fluids used for
neurologic intensive care unit. Journal of Neuroscience dysphagia therapy. Journal of Food Science, 75(6), E330–
Nursing, 40(5), 291–298. E338.
Fricker, A., & Lewis, A. (2009). Better oral health in Scannapieco, F. A., & Mylotte, J. M. (1996). Relationships
residential care. Adelaide, SA: South Australian Dental between periodontal disease and bacterial pneumonia.
Service. Journal of Periodontology, 67(10s), 1114–1122.
Furness, S., Worthington, H. V., Bryan, G., Birchenough, Scully, C., & Felix, D. (2005). 3: Oral medicine—Update
S., & McMillan, R. (2011). Interventions for the management for the dental practitioner: Dry mouth and disorders of
of dry mouth: Topical therapies. Cochrane Database of salivation. British Dental Journal, 199(7), 423–427.
Systematic Reviews, 2001(12), Art. No. CD008934. Selley, W. G., Hon, F., Roche, M. T., Pearce, V. R., Ellis,
Gürgan, C. A., Zaim, E., Bakirsoy, I., & Soykan, E. (2006). R. E., & Flack, F. C. P. (1995). Dysphagia following strokes:
Short-term side effects of 0.2% alcohol-free chlorhexidine Clinical observations of swallowing rehabilitation employing
mouthrinse used as an adjunct to non-surgical periodontal palatal training appliances. Dysphagia, 10(1), 32–35.
Sjögren, P., Nilsson, E., Forsell, M., Johansson, O.,
treatment: a double-blind clinical study. Journal of
& Hoogstraate, J. (2008). A systematic review of the
Periodontology, 77(3), 370–384.
preventive effect of oral hygiene on pneumonia and
Hua, F., Xie, H., Worthington, H. V., Furness, S., Zhang,
respiratory tract infection in elderly people in hospitals and
Q., & Li, C. (2016). Oral hygiene care for critically ill patients
nursing homes: Effect estimates and methodological quality
to prevent ventilator-associated pneumonia. Cochrane
of randomized controlled trials. Journal of the American
Database of Systematic Reviews, 2016(10), Art. No.
Geriatric Society, 56(11), 2124–2130.
CD008367.
Strydonck, D. A., Slot, D. E., Velden, U., & Weijden, F.
Iinuma, T., Arai, Y., Abe, Y., Takayama, M., Fukumoto, M.,
(2012). Effect of a chlorhexidine mouthrinse on plaque,
Fukui, Y., . . . Gionhaku, N. (2014). Denture wearing during
gingival inflammation and staining in gingivitis patients:
sleep doubles the risk of pneumonia in the very elderly.
A systematic review. Journal of Clinical Periodontology,
Journal of dental research, 94(3 suppl), 28S–36S. 39(11), 1042–1055.
Jessup, R. L. (2007). Interdisciplinary versus Tablan, O. C., Anderson, L. J., Besser, R., Bridges, C.,
multidisciplinary care teams: Do we understand the & Hajjeh, R. (2004). Guidelines for preventing healthcare-
difference? Australian Health Review, 31(3), 330–331. associated pneumonia, 2003. Morbidity and Mortality
Juthani-Mehta, M., De Rekeneire, N., Allore, H., Chen, Weekly Report, 53(RR-3), 1–36.
S., O’Leary, J. R., Bauer, D. C., . . . Quagliarello, V. Terpenning, M. (2005). Geriatric oral health and pneumonia
(2013). Modifiable risk factors for pneumonia requiring risk. Clinical Infectious Diseases, 40(12), 1807–1810.
hospitalization of community-dwelling older adults: The van der Maarel-Wierink, C. D., Vanobbergen, J. N.,
Health, Aging, and Body Composition Study. Journal of the Bronkhorst, E. M., Schols, J. M., & de Baat, C. (2013). Oral
American Geriatric Society, 61(7), 1111–1118. health care and aspiration pneumonia in frail older people:
Langmore, S. E., Terpenning, M. S., Schork, A., Chen, A systematic literature review. Gerodontology, 30(1), 3–9.
Y., Murray, J. T., Lopatin, D., & Loesche, W. J. (1998). Wagner, E. H. (2000). The role of patient care teams
Predictors of aspiration pneumonia: How important is in chronic disease management. British Medical Journal,
dysphagia? Dysphagia, 13(2), 69–81. 320(7234), 569.
Lim, M. A. W. T., & Borromeo, G. L. (2017). Special Watando, A., Ebihara, S., Ebihara, T., Okazaki, T.,
needs dentistry: Interdisciplinary management of Takahashi, H., Asada, M., & Sasaki, H. (2004). Daily oral
medically-complex patients at hospital-based dental units care and cough reflex sensitivity in elderly nursing home
in Tasmania, Australia. International Journal of Medical patients. CHEST Journal, 126(4), 1066–1070.
Research and Health Sciences, 6(6), 123–131. Waxman, M.J., Durfee, D., Moore, M., Morantz, R.A.,
Loeb, M. B., Becker, M., Eady, A., & Walker-Dilks, C. & Koller, W. (1990). Nutritional aspects and swallowing
(2003). Interventions to prevent aspiration pneumonia in function of patients with Parkinson’s disease. Nutrition in
older adults: A systematic review. Journal of the American Clinical Practice, 5(5), 196–199.
Geriatrics Society, 51(7), 1018–1022.
Martin, B. J., Corlew, M. M., Wood, H., Olson, D., Dr Mathew Lim is a dentist who works in the area of Special
Golopol, L. A., Wingo, M., & Kirmani, N. (1994). The Needs Dentistry.
association of swallowing dysfunction and aspiration
pneumonia. Dysphagia, 9(1), 1–6. Correspondence to:
Marunick, M., & Tselios, N. (2004). The efficacy of palatal Dr Mathew Lim
augmentation prostheses for speech and swallowing in Alfred Hospital Dental Clinic
patients undergoing glossectomy: A review of the literature. The Alfred
The Journal of Prosthetic Dentistry, 91(1), 67–74. 55 Commercial Road, Melbourne Vic 3001
Mody, L., Maheshwari, S., Galecki, A., Kauffman, C. email: [email protected]
A., & Bradley, S. F. (2007). Indwelling device use and phone: (+61) 0403 150 649
antibiotic resistance in nursing homes: identifying a high-risk

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