You can’t underestimate the importance of good oral hygiene for overall health and wellbeing.
This is particularly important for people with dysphagia. Swallowing difficulties increase the risk of harmful bacteria from the mouth getting into the lungs, which could result in bacterial infections and pneumonia.
Researchers have found a high incidence of poor oral hygiene in people with dysphagia related to problems with saliva production, oral cleanliness, the tongue and use of dentures, and this was associated with a high prevalence of opportunistic, harmful bacteria in the mouth.
Ironically, this issue has risen to the fore as better oral care has reduced the need for dentures. Why? Because dentures are easy to take out and soak in an anti-bacterial solution.
Bacterial overgrowth and related prevalence of plaque and gum infection often go unnoticed. If this results in aspiration pneumonia, there is a greater need for hospitalisation, which in turn can impact oral hygiene.
Furthermore, dysphagia can be a symptom of neurological, cerebrovascular and neurodegenerative disorders that can require hospitalisation and hinder communication.
Thus, as Weimers and Pillay write, this makes “dysphagia and its repercussions such as oral bacterial colonisation a highly invisible disorder and a silent epidemic”.
People with dysphagia who depend on others for their oral care, who have a low level of alertness or are bed-ridden are at increased risk of poor oral care, and in turn, aspiration pneumonia.
Other contributing factors to poor oral care and pneumonia in dysphagia patients include endotracheal intubation (a tube placed into the windpipe through the mouth or nose to assist breathing) and enteral nutrition (feeding via a tube placed in the mouth or nose).
Texture modification of food for greater ease of swallowing, according to international diet guidelines, can also lead to food sitting in the mouth and facilitate growth of decay-causing bacteria and plaque. This is exacerbated by high levels of starches or carbohydrates typically used to thicken fluids.
Mathew Lim, from the University of Melbourne, has published detailed guidelines for awareness and practice of oral care in patients with dysphagia.
The guidelines range according to dysphagia severity from using normal oral hygiene (brushing teeth and flossing) twice a day to brushing with a dry/damp toothbrush once to twice daily for patients with severe dysphagia who cannot eat or drink orally.
Broadly, it’s recommended that people with dysphagia receive or undertake oral care at least 2-3 times a day and before eating or drinking to minimise any bacteria that could accidentally go down the airway while swallowing. This also applies to cleaning of dentures, which should be completely removed so the gums and palate can be cleaned.
In care facilities, oral care kits should be kept by the bedside to make them easy and accessible. Education and encouragement for patients and care providers are recommended, with special attention also paid to oral care in patients with airway or nutrition tubing.