Oral Care/Oral Hygiene
and the
Impact on Dysphagia
The Importance of Oral Care
With a patient that has been made NPO (No Food Per Oral), the importance of strict oral care cannot be emphasized enough when providing patient’s and families education. There are several studies that provide ample ammunition for this laser focus on oral care with a new stroke patient, especially one that has recently been made NPO. Oral hygiene and dental care are important. Dried secretions that accumulate on the tongue and palate reduce oral sensitivity and promote bacterial growth. The elderly have an increased incidence of oropharyngeal colonization with respiratory pathogens, a well-known risk factor for pneumonia. Changes in the oral milieu may occur secondary to decreased salivary production and abnormalities in swallowing. These abnormalities may result in the impaired clearance of organisms, allowing for pathogenic colonization. A dependence on oral care is associated with poor oral health, subsequent weight loss and malnutrition, and altered colonization of the oropharynx.
Toothbrush
The best item to use in most situations is the toothbrush versus swabs which is found to be the most commonly used item to clean teeth. Pearson and Hutton (2002) examined dental plaque removal with 34 volunteers and reported that toothbrushes were substantially better at removing plaque than foam swabs. Oral care should include use of dentifrices and/or mouth rinses. Houston et al. (2002) reported that oral rinses mixed with a 0.12% solution of chlorhexidine reduced the rate of pneumonia in heart surgery patients by 52%. Beraldo and de Andrade (2008) identified eight meta-analyses and randomized clinical trials examining chlorhexidine effectiveness. Seven (87.5%) reported chlorhexidine diminished oropharynx pathogen colonization and reduced ventilator-associated pneumonia. This actually makes a lot of intuitive sense, but some are often are hesitant to use a toothbrush with a patient that is NPO because we are afraid they may swallow the toothpaste or the water “down the wrong pipe” which is most often the reason they are NPO in the first place. We should either use a wet toothbrush without toothpaste or one with a very small amount with our high risk patients. However, I first want to refer you to the Frazier Free Water Protocol and the many references that state small amounts of PO swallowed will not likely cause respiratory stress. If the patient has respiratory precautions, then use water minimally, with the Semi-Fowler position and with extra precaution. Good oral hygiene is key ingredient to prevention of aspiration and the water protocol offers other benefits with regards to xerostomia and swallowing. Aggressive oral care is extremely important and refers to brush your teeth, tongue, gums and roof of mouth with toothbrush and toothpaste, and you floss; even if you are on a restricted diet.
Without vigilant observation and intervention, NPO patients will get thrush. Besides being painful, thrush can have serious medical implications for our patients. Xerostomia (dry mouth) can lead to thrush and is caused primarily by medications, can significantly and negatively impact nutrient intake, but can also be caused by radiation therapy if the salivary glands are compromised or by Sjogren’s syndrome, a disorder that attacks the salivary glands among other things. Cavities are also a big problem for our patients. A study by Susan Langmore notes that a patient’s number of cavities was a leading risk factor for developing aspiration pneumonia in adults receiving medical care. See Predictors of Aspiration Pneumonia (AP) for further details as well as the handouts below as to how to give the best oral care possible when taking care of someone else.
If you feel confident that the patient is cognitively intact enough to do it, then using alcohol free rinse can be a good adjunct to tooth-brushing. It’s important to use alcohol free rinse, because alcohol dry’s out the mouth. I don’t usually recommend one brand over another, but just make sure you keep away from the alcohol!
With a patient that has been made NPO (No Food Per Oral), the importance of strict oral care cannot be emphasized enough when providing patient’s and families education. There are several studies that provide ample ammunition for this laser focus on oral care with a new stroke patient, especially one that has recently been made NPO. Oral hygiene and dental care are important. Dried secretions that accumulate on the tongue and palate reduce oral sensitivity and promote bacterial growth. The elderly have an increased incidence of oropharyngeal colonization with respiratory pathogens, a well-known risk factor for pneumonia. Changes in the oral milieu may occur secondary to decreased salivary production and abnormalities in swallowing. These abnormalities may result in the impaired clearance of organisms, allowing for pathogenic colonization. A dependence on oral care is associated with poor oral health, subsequent weight loss and malnutrition, and altered colonization of the oropharynx.
Toothbrush
The best item to use in most situations is the toothbrush versus swabs which is found to be the most commonly used item to clean teeth. Pearson and Hutton (2002) examined dental plaque removal with 34 volunteers and reported that toothbrushes were substantially better at removing plaque than foam swabs. Oral care should include use of dentifrices and/or mouth rinses. Houston et al. (2002) reported that oral rinses mixed with a 0.12% solution of chlorhexidine reduced the rate of pneumonia in heart surgery patients by 52%. Beraldo and de Andrade (2008) identified eight meta-analyses and randomized clinical trials examining chlorhexidine effectiveness. Seven (87.5%) reported chlorhexidine diminished oropharynx pathogen colonization and reduced ventilator-associated pneumonia. This actually makes a lot of intuitive sense, but some are often are hesitant to use a toothbrush with a patient that is NPO because we are afraid they may swallow the toothpaste or the water “down the wrong pipe” which is most often the reason they are NPO in the first place. We should either use a wet toothbrush without toothpaste or one with a very small amount with our high risk patients. However, I first want to refer you to the Frazier Free Water Protocol and the many references that state small amounts of PO swallowed will not likely cause respiratory stress. If the patient has respiratory precautions, then use water minimally, with the Semi-Fowler position and with extra precaution. Good oral hygiene is key ingredient to prevention of aspiration and the water protocol offers other benefits with regards to xerostomia and swallowing. Aggressive oral care is extremely important and refers to brush your teeth, tongue, gums and roof of mouth with toothbrush and toothpaste, and you floss; even if you are on a restricted diet.
Without vigilant observation and intervention, NPO patients will get thrush. Besides being painful, thrush can have serious medical implications for our patients. Xerostomia (dry mouth) can lead to thrush and is caused primarily by medications, can significantly and negatively impact nutrient intake, but can also be caused by radiation therapy if the salivary glands are compromised or by Sjogren’s syndrome, a disorder that attacks the salivary glands among other things. Cavities are also a big problem for our patients. A study by Susan Langmore notes that a patient’s number of cavities was a leading risk factor for developing aspiration pneumonia in adults receiving medical care. See Predictors of Aspiration Pneumonia (AP) for further details as well as the handouts below as to how to give the best oral care possible when taking care of someone else.
If you feel confident that the patient is cognitively intact enough to do it, then using alcohol free rinse can be a good adjunct to tooth-brushing. It’s important to use alcohol free rinse, because alcohol dry’s out the mouth. I don’t usually recommend one brand over another, but just make sure you keep away from the alcohol!
ORAL CARE RESOURCES
A very good resource that has wonderful handouts to help you as a caregiver with your loved one's oral care is umanitoba.ca/dentistry/ccoh/ccoh_longTermCareFacts.html
University of Manitoba: U of M - Dentistry - Mouthcare Resources for U of M - Dentistry - Mouthcare Resources for Caregivers: Fact Sheets ... of Manitoba's Centre for Community Oral Health (CCOH) expanded its focus in .... Tel 204-789-3631 Fax 204-789-3912 Email info_dent@umanitoba.ca
University of Manitoba: U of M - Dentistry - Mouthcare Resources for U of M - Dentistry - Mouthcare Resources for Caregivers: Fact Sheets ... of Manitoba's Centre for Community Oral Health (CCOH) expanded its focus in .... Tel 204-789-3631 Fax 204-789-3912 Email info_dent@umanitoba.ca
A Caregiver's Guide to Dental Care Every Day
| dentalcareeveryday.pdf |
Basic Oral Care for People
with Dentures/without Teeth
| basicmouthcarewithoutteethaugust2010.pdf |
DRY MOUTH/XEROSTOMIA
| drymouth.pdf |
Practical Oral Care for People with
Cerebral Palsy
| poccerebralpalsy.pdf |
