8/12/2014
RELATIONSHIPS
BETWEEN DYSPHAGIA,
ORAL HEALTH, AND
DENTITION
Disclosures
I do not have potentially biasing relationships of a financial,
professional, or personal nature with any commercial
interests that would constitute a conflict of interest related
to this talk.
Jeff Searl, Ph.D., CCC-SLP
Associate Professor
Hearing and Speech Department
KU Medical Center
Overview
What is Oral Health?
• Definition of oral health and disease
• World Health Organization’s definition (2013)
• Scope of the problem: Oral Health
• USA
• KS and MO
• Key items to review
• Dentition, occlusion
• Mastication
“a state of being free of mouth and facial pain, oral and
throat cancer, oral infection and sores, birth defects such
as cleft lip and palate, periodontal(gum) disease, tooth
decay and tooth loss, and other diseases and disorders
that limit an individual’s capacity in biting chewing, smiling,
speaking, and psychosocial wellbeing.”
• Oral biofilm development
• Linkages:
• Oral health/dentition
• Oral health/Dentition
Overall Health
Dysphagia
• Narrowing our focus today
• Dental status
• Health of the oral environment (beyond the teeth to include oral biofilm,
gum tissue; but excluding cancer, cleft/cranio, trauma/surgical issues)
What is Oral Disease? (WHO)
• Dental Caries
Major cause of tooth loss
• Periodontal Disease
• Gingivitis – inflammation of gums
• Periodontitis – inflammation then breakdown of bone and tissue that
anchors teeth in mouth
• Oral Infectious Disease (fungal, bacterial, viral)
• Cancer
• Oro-dental Trauma
• Noma
Not part of today though
• Cleft lip and palate
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Scope of the Problem
Oral Health & Dentition in the Elderly:
Scope Nationally
National Oral Health Objectives
• Healthy People 2020
• US Dept of Health and Human Services
• Older adults in America
• 2009 – 39.6 million seniors in US
• 2030 – 72.1 million seniors
projected in US
• Disease prevention and health promotion initiative
• Public health goals for the next decade (done every 10 yrs)
• 42 Topic areas - ~600 objectives, 1200+ measures
• Leading Health Indicators – subset with high priority
• ORAL HEALTH = a Leading Health Indicator for 2020
http://www.toothwisdom.org/
http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=32#186
Scope Nationally
Oral Health & Dentition in the Elderly:
• Main oral health &
dentition issues – big
picture
• Key Resources
•
•
•
•
•
past yr
• At poverty level = 26%
• 200%-399% PL = 41%
• >400% PL = 55%
v/2020/LHI/oralHealth.aspx?
tab=overview
• Race/Ethnicity-dental visit
• Native Hawaiian/Pac = 24%
• Hispanic = 30%
• Black, non-Hispanic = 30%
• Am Ind/Alaska Nat = 37%
• Asian = 37%
• White, non-Hispanic = 48%
• http://www.toothwisdom.org/
Scope Nationally
Disparities Among Older Adults
• Risk for oral conditions (edentulism, cancer, periodontal disease, etc.)
• Amplified if …
• Income – dental visit in
• 100%-199% PL = 30%
• http://www.healthypeople.go
• Disparities in dental health
across older adults
populations
Impact on overall health
Lack of dental providers
Paying for dental care
Flouridation
Edentulism
Scope Nationally
Disparities
(Borrel, Burt & Taylor, 2005)
• Low income
• Racial or ethnic minority
Scope Nationally
Disparities – where you live
• Metro/urban vs. non-metro/rural: more visits for metro/urban
• Institutionalized Elderly
• NIDCR – recognizes frail/dependent elders in NH as significant health
risk re: oral health (NIDCR, 2002)
• Consistent finding across studies = very high occurrence of oral health
problems (Jablonksi et al, 2005)
• No or poor dental insurance
• Cognitive or physical disability
• Institutionalized or homebound elderly
• Low education level
• Now retain natural teeth longer, but high percentage are diseased
• Increased caries, gingival recession, reduced salivary flow (med related in
most instances)
• Large percentage of NH residents lack cognitive and/or functional ability to
perform their own oral care – 70%?
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Scope of the Problem - KANSAS
Oral Health Kansas - resources
Scope of the Problem – KANSAS
• Healthy Kansans 2020
• 2011-2014 KS Oral Health
Plan
• http://www.oralhealthkansas.
• KDHE in partnership with …
org/OlderKansans.html
• http://www.kdheks.gov/ohi/
• http://www.kdheks.gov/ohi/do
wnload/2012_Elder_Smiles_
Report.pdf
• 10yr strategic plan
• Bureau of Oral Health
• 3 main themes
• Healthy Living
• Healthy Communities
• Access to Services
• 3 Sections
• Educate re: oral health-general
health link
• Advocate for better oral health
for all pops
• Ensure KS dental workforce can
meet the need
• Oral Health listed as 1 of 12
http://www.kdheks.gov/ohi/download/
Burden_of_oral_disease_in_Kansas.
pdf
focus areas but no specific
objectives other than HP2020
• http://healthykansans2020.org/#
&panel1-1
2012 Elder Smiles
Scope of the Problem: Kansas
2012 Elder Smiles Report
Percent by Age Group
2012 Elder Smiles
65-74
75-84
85-94
95+
Total
Edentulous
24
33
37
25
33
Oral Debris
33
22
31
36
29
Suspicous Lesions
4
4
2
2
3
Untreated Decay
52
22
36
36
34
Root Fragments
25
13
17
26
17
Gingivitis
37
22
23
33
26
Tooth Mobility
19
15
13
17
15
TX Urgency
No Obvious Problem
Early Care Needed
Urgent Care Needed
58
34
8
77
18
4
73
24
3
67
33
0
72
24
4
2012 Elder Smiles – Key Findings
QUESTIONNAIRE DATA
Dental Insurance
No
Yes
84
16
<12mos
>12 mos
47
53
Oral Pain last 6mos?
Most of the time
Some of the Time
Seldom
3
15
82
Dry Mouth?
Most of the time
Some of the Time
Seldom
16
31
53
Limit Food You Eat bc Teeth?
Most of the time
Some of the Time
Seldom
13
17
70
No
Yes
36
64
1.
1/3 of KS nursing home residents have no natural teeth
• vs. 17.4% of all Kansans >65 yrs of age
Last Cleaning
Brush teeth/dentures Daily?
• vs. 21.6% target from HP 2020 (KS does well with those over 65 UNTIL we look at NH
residents)
2.
NH Residents had significant dental care previously, but now
have untreated disease
• Hygienists noted large # with crowns, restorations, fillings, bridges indicating prior care
• But once in NH – untreated dental problems arise
• “For many nursing facility residents, it appears that regular dental care has become a
thing of the past.”
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2012 Elder Smiles – Key Findings
2012 Elder
Smiles
3. NH Residents have poor oral hygiene
• Most had gingivitis to some degree; 26% had severe gingivitis
• 29% had oral debris on at least 2/3 of teeth
• 15% had loose teeth
4. NH Residents have limited resources for dental care
• 16% had private dental insurance
• 66% on KS Medicaid = limited dental benefit (assests of $2K or less and
income of $62/month or less)
Kansas
Lack of Providers
• Dental workforce is aging
• Across the United States (US Dept of Health and Human Services,
2010)
• 45-54yrs old = 26%
• >55yrs old = 37%
• Within our states
• KS
• 2009 Oral Health Workforce Assessment
• 54% of dentists in rural/frontier areas planning to retire in the next 3-5 years
• Most with no interested buyers of the practice
• 2011 Oral Health Workforce Assessment Project: Mapping the Workforce
• MO – 2011 MO Oral Health Access Report
Kansas
Paying for Dental Care
• Dental Insurance is a major problem for older adults
• Not addressed in the Affordable Care Act
• Private Insurance is expensive for older adults
• Public insurance
• Medicare coverage = almost non-existent (not for routine dental care)
• Medicaid = limited by state programs
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Oral Health America: State Ratings
Dentition Reminders: Sets of Teeth
• Primary (“milk”,
deciduous)
• erupt @ 6-24 months
• N=20
• quadrant includes:
• central incisor
• lateral incisor
19th
• canine
• molars x2
27th
Dentition Reminders: Sets of Teeth
• Permanent
• erupt over ~10 years
• N=32
• quadrant includes:
Dental Reminders: occluding surfaces
• Functional tooth units
and posterior occluding
pairs (POPs)
• central incisor
• lateral incisor
• canine
• 1st & 2nd bicuspids
• 1st, 2nd, & 3rd molars
Chewing Process Reminder
• Chewing as part of the normal eating/swallowing process
• Palmer et al (1992), Hiiemae & Palmer (1999), Mikushi et al (2014)
• “Process Model of Feeding”
• Stage I Transport = solid moved anterior oral cavity to post canine
region for mastication
Chewing Process Reminder– the goal
• Form a bolus that is:
• Malleable/soft
• Lubricated
• Cohesive
• Processing (Chewing) = reducing food to “swallowable” consistency
• Stage II Transport = moving chewed food posteriorly by squeezing
tongue to palate to get food from oral cavity to pharynx [or allowing it to
flow over posterior oral tongue] (can co-occur with Processing)
• Pharyngeal transport = moving from pharynx into esophagus
http://www.youtube.com/watch?v=GqFKMd
CqN7U
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Changes in mastication as we age
• Increased # of cycles of chewing
per bolus
Changes in mastication as we age
• But older folks produce a better
bolus (more consistent particle
size, fewer large particles) (Hatch
(Feldman et al, 1980; Woda et al
2006 )
et al, 2001)
• Increased duration of chewing
sequence
• Decreased masticatory muscle
mass and bite force (but same
EMG activity = increased “effort”
in mastication) (Peyron et al, 2004)
Changes in mastication as we age
Chewing related – saliva and aging
reminder
• Denture Impact vs. Dentate?
• Histology of salivary
• Increased # chews, increased EMG
glands changes in
elderly
activity, increased chew sequence duration
with Dentures for hard solids
• Other studies suggest 50-85% deceased
efficiency in mastication in denture wearers
in denture wearer
the glands decreases
• Less ability to adapt to food hardness
• Medications =
primary factor
Biofilm
• “…assemblage of surface-associated microbial cells that is
enclosed in an extracellular polymeric substance matrix.” (p.881,
Donlan, 2002)
• 75% of those >65yrs
taking at least 1 med
• 16%-30% report oral dryness
• Yet perceived oral
dryness (xerostomia)
is quite common with
advancing age
Chewing related – saliva and aging
reminder
or older
decrease in salivary
production volume that
is age-related
• And tissue volume of
• Less consistency and quality of the bolus
• Non-institutionalized 65yrs
• BUT no meaningful
• 400+ known to cause
dryness
• “The number of these animalcules in the scurf of a man’s teeth are
so many that I believe they exceed the number of men in a
kingdom.” – Antonie Van Leeuwenhoek, 1683 letter to the Royal Society of
London re: plague from his, wife’s, daughter’s and two old men’s teeth.
• Institutionalized elderly
• From late 1970’s until now – significant study and advancement of
• 44%-61%
• Others = systemic
understanding (SEM, genetics most recently)
disease, XRT,
dehydration
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Biofilms
• Occur on many surfaces (bodies of water, mechanical
systems, medical equipment, etc.)
Oral Biofilms
• Happen on
• Gingival surfaces (esp. crevices)
• Differ genetically and in construction from free-floating
(planktonic) microbes
• Composition:
• Microbial cells
• Extracellular Polymeric Substances (EPS)
• Cellular debris
• Biofilms have their own ecology
• Teeth = PLAQUE
• Dentures/appliances = PLAQUE
• Plaque is more often the focus (research) but clinically
worry about all
• Removal of plaque?
• Reminder of types of bacteria
Oral Biofilm Development
Dental Plaque – SEM images
And more
Impact on General Health
• As dental plaque matures = incr. gram negative anaerobic bacteria
• Major emphasis in the lit the past 10+ years
• US Surgeon General’s Report back to 2000
• Systematic reviews to the present
• General ground swell of acceptance of a link between oral
health and overall health
• Much to be learned
• But extremely compelling
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Linkages: Oral Health – Overall Health
• Most research in this
area has focused on
periodontitis and
damage to highly
vascular periodontal
tissue (route to cause
trouble elsewhere in
the body)
Linkage: Oral Health - Dysphagia
• Let’s focus
first on just
teeth for a
moment
• Peek et al 2002:
Florida Dental Care
Study – longitudinal,
n=800+
CONDITIONAL
PROBABILITY:
probability of an
event (A), given that
another (B) has
already occurred.
Revisit Demographics for
a moment – chewing
specific
Peek et al 2002: Florida Dental Care Study – longitudinal, n=800+
• Peek et al
2002: Florida
Dental Care
Study –
longitudinal,
n=800+
Teeth - Impact on Chewing & Swallowing
• Tooth pain
• Anterior teeth = incising/tearing of foods at issue –
Stage I Transport (Palmer)
Teeth - Impact on Chewing & Swallowing
• Tooth pain - Food choice
• Large scale studies (cross-sectional and longitudinal) –
• National Diet and Nutrition Surveys (NDNS – UK)
• National Health and Nutrition Examination Survey (NHANES – US)
• Primary findings – food avoidance leading to decreased intake of
• Posterior teeth = mashing/grinding
…
•
•
•
•
•
Dietary fiber
Vitamin C
Retinol
Folate
Beta-carotene
• Secondary consideration – food “over preparation” leading to …
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Teeth - Impact on Chewing & Swallowing
• Number of teeth in the
mouth matters
• Chewing probs when >7 teeth
are missing (Olga et al, 2012
systematic review)
• Increase bolus size with
Vs 25-32 Teeth OR (of having 95% CI
swallowing
problem)
0-13
2.04
1.602.60
14-24
1.31
1.021.70
Okamoto, et al. (2012)
increased # of missing teeth
(Mishellany et al, 2006)
Teeth - Impact on Chewing & Swallowing
• Functional tooth units– (Olga et al, 2012 systematic
review, >65yrs old)
• Chewing difficulty increased with decreasing # functional tooth units (n=10
studies)
• Somewhere btw 5-7 POPs = good chewing function
• 3-4 POPs = “turning point” from adequate to insufficient
• <2 POPs = significant chewing problems
• Natural vs prosthetic functional tooth units?
• Those with fewer natural teeth had greater chewing problems than those with
• Poorly degraded bolus
swallowed despite increased
chew cycles (Feldman, et al,
1980; Wayler et al, 1983)
Teeth - Impact on Chewing & Swallowing
• Impact of dentures? Some controversy but…
• Ill-fitting dentures are not helpful – significantly increases duration
of the swallow [Monaco et al, 2012]
• denture wearing [Yoshida et al, 2013]
• significantly shortened pharyngeal transit time
• Others have shown less efficiency in chewing with full dentures (as
reviewed by Woda et al, 2006)
•
•
•
•
Increased # chew cycles
Increased duration of mastication sequence
EMG activity per sequence
Despite increased “work” of chewing, coarser bolus resulted
Summary: Tooth Pain-Loss and Why
SLPs should care
prosthetics (n=3 studies)
• BUT…
Summary: Tooth Pain-Loss and Why
SLPs should care
• Documented changes
• Food choice
• Trouble tearing/biting (anterior problems)
• Increased solid bolus size
• More poorly degraded bolus
• Natural teeth
> few/no teeth
> dentures (well or poor fitting)
- Incr chew cycles
- Incr duration chew sequence
- Incr EMG activity
- coarser bolus
• Well-fitting Dentures > few/no teeth
• Poor-fitting Dentures ~ few/no teeth
Summary: Tooth Pain-Loss and Why
SLPs should care
Impact on what we do/think/understand
1.
Diagnostic process
• Careful examination of the mouth/teeth - #, units/POPs, condition
• Impact on what we do/think/understand
2. Diagnostic thinking/understanding of the problem
• Can they tell you if they have dental pain?
• Attention to tissue dryness – review of other reasons why possibly dry
• Meal time observations – food/texture avoidance
• Selection of foods for bedside/instrumental exam
2.
Diagnostic thinking/understanding of the problem
• Why are they chewing the way they are? Why aren’t they chewing
much?
• Why swallowing such a big bolus of solids?
• Possibility that pharyngeal issues are related to chewing in this pt?
• Are the dentures impacting other parts of the swallow?
• Esophageal swallowing symptoms related to chewing? Better chewed foods
are more easily cleared from esophagus (Pouderoux et al, 1999)
• Tooth pain or loss in combo with underlying disease (comorbidity)
• Myasthenia Gravis, ALS, XRT/reconstruction etc. – chewing fatigue/effort
amplified?
• Amplifier of other dysphagia problems (e.g., reduced pharyngeal contraction +
less poorly chewed bolus due to pain/tooth loss?)
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Oral Health and Dysphagia – beyond
dentition
Oral Health and Dysphagia – beyond
dentition
• Significant work in the last 15+ years detailing this
• Simple over-view then some details
• Bacterial colonization in the mouth as part of biofilm
relationship – particularly for stroke patients, and nursing
home residents
• Primary focus has been poor oral health as reflected by
altered oral flora/biofilm and what happens if this is
aspirated
• Decayed teeth, xerostomia, plaque, periodontal disease = increase of
anaerobic bacteria in the mouth (Eisenstadt, 2010)
• Aspiration of this bacteria in the biofilm = increased risk of
developing pneumonia
• Those with dysphagia are more likely to aspirate the “bad stuff”
• Those with dysphagia also are more likely to have decreased immunity,
poorer pulmonary clearance, and poorer nutrition (Marik & Kaplan,
2003; Terpenning et al, 2001; Young and Steele, 2007)
Oral Health and Pneumonia and
Respiratory Tract Infection
• Pneumonia-oral health association: II-2
Systematic Review of the Association
Between Respiratory Diseases and Oral
Health
Amir Azarpazhooh* and James L. Leake*
Journal of Periodontology
September 2006, Vol. 77, No. 9, Pages 14651482 , DOI 10.1902/jop.2006.060010
(doi:10.1902/jop.2006.060010)
Oral Health and Dysphagia
• Classic work by Susan Langmore et al, 1998
evidence, B Rx
• COPD-oral health association: II-2/3, C
Rx
• Improved oral hygiene/professional oral
health – occurrence/progression
respiratory disease: I, A Rx
• Level I: Evidence obtained from at least one properly designed randomized controlled trial.
• Level II-1:Evidence obtained from well-designed controlled trials without randomization.
• Level II-2:Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more
than one centre or research group.
• Level II-3:Evidence obtained from multiple time series with or without the intervention. Dramatic results in
uncontrolled trials could also be regarded as this type of evidence.
• Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of
expert committees.
Aspiration pneumonia development – is
dysphagia important?
Langmore et al., 1998
• Susan Langmore et al, 1998
• SURPRISE – no dysphagia in the predictor variable list!
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Langmore et al., 1998
• Why no dysphagia in the models? Dysphagia variables =
highly correlated with other strong predictor variables.
Langmore et al., 1998
• Once aspiration occurs – host
defenses have to kick in to
prevent problems
• Mechanical defenses
• When considering who get AP –oral cavity colonization
and host resistance must be considered
• Cough defense
• Mucocilliary defense
• Cellular defense
• Lymphatics
• Alveolar macrophage
• How is bacterial flora altered?
• Disease, inactivity, malnutrition, ORAL or DENTAL DISEASE
(plague, gingivitis, periodontal disease)
• Saliva (or bolus material) mixing with the flora
Other studies/reviews of importance since
Langmore et al 1998
• Azarpazhooh and Leake (2003)
• Scanipiecco et al (2003) =
= systematic review looking at
relation btw oral health and
bacterial pneumonia
systematic review of relation btw
oral health and bacterial
pneumonia
• Relative risk of 9.6 with dental
• Important risk factors
plaque colonization
• Decayed teeth
• Awano et al (2008)
• Pneumonia related deaths and periodontal disease in n=697
• People with 10+ periodontal pockets had increased mortality rate from pneumonia
• Periodontal pockets = increased periodontal bacteria (esp gram negative)
• Cariogenic and periodontal
pathogens in dental plaque
Other studies/reviews of importance since
Langmore et al 1998
RR=
P of event when exposed
P of event when non-exposed
RR of 1: no difference in risk between the two groups.
RR of < 1: event is less likely to occur in the experimental group than in
the control group.
RR > 1: means the event is more likely to occur in the experimental
group than in the control group.
• Gram negative produce high levels of methyl mercapitan (CH3SH) on tongue
surface
• Those who died of asp pneumonia =higher levels of CH3SH
• Those who died of asp pneumonia = higher Candida species on tongue == possibly
indication of reduced immunocompetency to fight off the infection
Oral Health and Pneumonia and
Respiratory Tract Infection
J AM Geriatr Soc 2008; 56: 2124-2130
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Results from the 4 RCTs reviewed
Oral Health and Pneumonia and
Respiratory Tract Infection
Results from the non-RCTs
What to do?
Nationally
State-wide
Institution
J AM Geriatr Soc 2008; 56: 2124-2130
INDIVIDUAL
PATIENT
MAIN CONCLUSION: prevention of pneumonia or respir tract infection in elderly
can be improved with oral hygiene intervention – greatest effects with:
1. Weekly professional oral care AND
2. Tooth brushing after every meal (combo with 1% providone iodine scrub
of pharynx as needed)
Patient Level
1. Understand their dysphagia
a) Neuro, structural (dental, surgical result, etc.), behavioral,
cognitive influences
b)
Assessment of dental/oral status – what can/should we do?
1)
Knowledge
and Skills
Needed by
SLP Dysphagia:
http://www.as
ha.org/policy/
KS200200079.htm#s
ec1.3
ASHA – scope of practice?
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Patient Level
Patient Level
• Knowing how to do it and what you are seeing? A few
1. Understand their dysphagia
resources
Assessment of dental/oral status – what can/should we do?
b)
2.
• NIDCR: Oral Cancer Screen for Health Care Professionals (extracted
from WHO’s standardized oral exam, consistent with CDC and NIH
methods)
Understand their dental/oral situation
- look in their mouth
http://www.nidcr.nih.gov/OralHealth/Topics/OralCancer/DetectingOralCancer.
htm
- ask … them, family
- collaborate with other providers
• University of Iowa Oral Pathology Image Database
http://www.uiowa.edu/~oprm/AtlasWIN/AtlasFrame.html
- dental (DDS, hygienists)
- MDs
• Iowa Geriatric Education Center
http://www.healthcare.uiowa.edu/igec/resources-educatorsprofessionals/dentistry/
- nursing and nurse assistants
Patient Level
• Knowing how to do it and what you are seeing?
• Not just a cursory glance inside the mouth
• Screen (not diagnose) dental/oral health as it might impact
chewing, swallowing
• Possible screening tool on next page
• In-service/training with dental professionals for you and your
team (nurses, CNAs, SLPs, etc.)
Patient Level
Patient Level
Understanding their dental/oral situation
Understanding their dental/oral situation
1. Diagnostically – influences
•
Choice of food materials to assess (bedside or MBS)
•
Choice of instrumental exam?
•
•
MBS lat + ant to see motion;
•
FEES to see bolus construction as it enters the pharynx; shape/construction of residue
2. Treatment Planning
Addressing dental/oral status as part of full dysphagia intervention plan – Pace
•
McCullough approach in just a moment
•
Assessing likelihood of improving (then maintaining) oral health status moving
forward?
•
How conservative-aggressive to be with oral intake?
Understanding of the dysphagia that is present (at least consider the possibility that
•
Timeline for reassessing swallow if oral health plan is implemented?
chewing, oral aversion, etc. might be impacting)
•
•
Facilitating this somehow – caregiver support, finances
Determining appropriate solids considering dental/oral status
•
Not just ability to comminute the food
•
Time/energy expended if chewing is less efficient (particularly for subgroups with fatigue)
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Patient Level
INSTITUTIONALLY – what to do?
Pace and McCullough, 2010
• What to do to in terms of oral care to reduce aspiration
• Check the medication list
• MD/Pharm consultations
• Xerostomia as a main concern
• Other side effects of concern – alertness, agitation, nausea, etc.
• Modify as necessary and possible
pneumonia risk in medically compromised/ill folks who are
hospitalized or in nursing home?
• Improved oral care and use of professional care can reduce
aspiration pneumonia by ~40% in high risk pts in nursing home
• Mechanical oral hygiene may
• Prevent 1 in 10 deaths from pneumonia in dependent elderly
• Significantly prevent occurrence of pneumonia
http://www.amda.com/tools/clinical/oralhealth.cfm
INSTITUTIONALLY – what to do?
• Establish an oral care assessment standard of care –
then actually follow it.
• Not an SLP task per se to do the care – but
• Understand who is to do what when – and establish checks
• Contact state resources with a vested interest in oral health
• If you aren’t happy with the oral care at your facility…
• Read the lit and arm yourself
• Find willing partners internally to push for change
Pace and McCullough, 2010 - specifics
• Chemical interventions
• Chlorhexidine gluconate (CHX) – usually 0.12% - antiseptic rinse
• Reduces gram positive and negative bacteria
• DeRiso et al 1996 – cardiovascular surgery patients = oropharyngeal
rinse reduced nosocomial infections by 65%
• Fourrier et al 2000 – ICU mechanically ventilated patients had decrease
in nosocomial infections and ventilator related pneumonia
• Tantipong et al 2009 – RCT, ventilator related pneumonia, CHX plus
mechanical cleaning reduced VAP to 5% vs, 11% in control group
• (providone iodine scrub used by others)
• Mechanical interventions!!!
• Excellence in Oral Health Awards – go for it
(http://www.oralhealthkansas.org/AwardWinners.html)
Pace and McCullough, 2010
• Regular, on-going oral health follow-up
• Don’t rely on oral swabs for mechanical cleaning of the mouth/teeth
(Pearson and Hutton, 2002; Pace and McCullough, 2010)
• Educate caregivers – uneducated caregivers contribute to poor oral
care. Show them the evidence (Stein and Henry, 2009)
• Evidence-based approach – RCTS + others are behind routine
care as a means of reducing respiratory complications, including
development of aspiration pneumonia
• Mechanical cleaning after every meal
• Regular professional dental care (the RCTs say weekly but is that
possible in your situation? Vs other countries)
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State Level
• Know the state Oral Health plan – and how your facility
(or you) are helping to implement/meet goals
• Know the players
• http://www.kdheks.gov/ohi/index.html
• http://www.oralhealthkansas.org/index.html
• http://www.astdd.org/state-programs/ - Association of State &
Territorial Dental Directors
• A role for KSHA?
Two examples – of SLP interest
Nationally
• ???? Think like Japan??? But how to have an
influence???
• Cognitive issues
• ASHA role?
• Medicare change to include dental! Hahahahah – but one
can dream
• ???
• ??
•?
materials or saliva
Oral Health & Dementia – which direction
does this relationship run?
Oral Health & Dementia – which direction does
this relationship run?
• Others still relational but perhaps more intriguing
• Lot’s of correlational studies
• Correlation btw tooth loss and MMSE scores
Int J Clin Exp Med, 15; 1040-6
• Pneumonia – not talking aspiration of oral ingested
(n=55, Italy; Mummolo et al., 2014,
AND n=462, Japan, Saito et al, 2013)
• Fewer natural teeth for those with dementia
• Increased prevalence of caries
(several refs)
(several refs)
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8/12/2014
Oral Health & Dementia – which direction
does this relationship run?
• Some interesting other findings of possible relevance
• Pyramidal cell decrease occurred (with associated change in spatial
memory) when masticatory function decreased from molar extraction
in rats (Yamazaki et al, 2008)
• Reduction in acetylcholine concentration in cerebral cortex and
hippocampus of molarless rats associated with reduced learning
memory (Makiura, et al., 2000)
• Soft-diet feeding (no mastication required) in mice resulted in lower
synaptic density in cerebral cortex of mice and memory-learning
issues in adulthood (Yamamoto & Hirayam, 2001)
• Chewing activity increases blood flow in prefrontal cortex and
hippocampus (transcranial Doppler sonography by Ono et al, 2007;
fMRI by Onozuko et al., 2003)
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