The First Thing….

Oral Care is one of the first lines of defense in dysphagia management and in the prevention of aspiration pneumonia.   Oral care is always the first discussion I have in any treatment plan with any patient.

What do you know about oral care? Do you want to download an Oral Care handout?   Click here and enter your email address at the prompt.   The handout will be sent to your inbox.  This handout can be great for information on the importance of oral care along with a checklist for oral care steps.

Aspiration

Aspiration is defined as the “inhalation of either oropharyngeal or gastric contents into the lower airways, that is, the act of taking foreign material into the lungs.”  (http://emedicine.medscape.com/article/296198-overview)

What Causes the Pneumonia?

At one time, we thought the food/liquid that was aspirated was the most important factor in those who end up with aspiration pneumonia.  I remember being told early in my career to avoid foods/drinks with high sugar content because they will cause the person to develop pneumonia.

Even recently, I was told that patients were ok to aspirate any liquid as long as it is clear.  Any liquid that you can see through.  Even champagne.

Aspiration Pneumonia

There are many factors in developing aspiration pneumonia.  There are people walking around that aspirate on a daily basis that never develop pneumonia.  Others simply look at a  piece of pizza and bam, pneumonia.  In fact, many of our patients with head and neck cancer are what are known as “functional aspirators” or those people that aspirate but do not develop pneumonia from it. 

Health status, respiratory status, activity level, medications can all play a factor in the development of aspiration pneumonia.  A major factor is oral care.

Ew, Bacteria

Bacteria from the oral cavity and nares are the main culprits in causing aspiration pneumonia including:  Streptococus pneumoniae,Haemophilus influenza, Staphlococcus aureus, and gram-negative bacteria (Bacteroides, Prevotella, Fusobacterium).

Oral colonization of bacteria worsens with (Gomes et al 2003):

• Antibiotic use
• Oral disease
• Xerostomia
• Malnutrition
• Presence of teeth

Patients at Risk for Aspiration Pneumonia

• Patients who are dependent for oral care
• Have large numbers of missing teeth
• Dentures
• Have limited hand dexterity
• Decreased mental capacity
• Multiple medical co-morbidities
• Immunosuppressed
• Ventilator dependant
• Receive non-prandial feedings
• Have had a stroke
• Neurologically impaired
• Xerostomia
• Known dysphagia
• Poor access to professional dental care
• Active smoking
• Depression
• Use of sedative medicine
• Use of gastric acid-reducing medication
• Use of ACE inhibitor
• Poor feeding position

 Aspiration pneumonia is a 3 phase process:

• Colonizes pathogenic bacteria in the oropharynx
• Aspirates the bacteria into the airway
• Unable to clear the material and then develops a bacterial infection in the respiratory system

(Langmore S, Terpenning M., Schork A., Chen Y., Murray J., Lopatin D., Loesche W.  Predictors of aspiration pneumonia:  How important is dysphagia? Dysphagia 1998; 13: 69-81)

 

Proper oral care is essential in the elimination/reduction in this harmful bacteria.  Oral care consists of brushing with a toothbrush and a toothpaste containing fluoride.  Rinsing with a non-alcohol based mouthwash may also help with oral care.  There is new evidence that mouthwash that claims to kill bacteria kills ALL bacteria, good and bad.   

Lemon glycerine swabs are not made for oral care and can, in fact, be very drying to the oral mucosa.  They have no cleaning agent in them and can actually cause erosion to the enamel of the teeth, not to mention that they can irritate the mucosal membranes of the mouth an become very painful.

Toothette swabs do not create adequate friction to clean the oral cavity.  Toothette swabs can be great to add moisture to the oral cavity, but not for cleaning.   

Improper oral care can be linked to increased risk of stroke.

Oral Care Assessment:

The Oral Health Assessment Tool (OHAT) is a tool that is great for use in the SNF setting.  The user is able to rate the oral cavity condition and assign severity to oral care or lack of.  It also prompts for an admission rating and quarterly ratings.   This tool can be used in any setting although the primary focus of the development of the tool was for the SNF setting.   

You can also learn more about the OHAT and other Outcome Measures.

The Necessity of Oral Care

Oral care is an absolute necessity during a bedside evaluation.  Have you ever tried to chew and swallow a cracker with a severely dry mouth or after you have not brushed your teeth for days?  It’s not easy.  While helping the patient or performing oral care, you have a great opportunity to educate the patient/family member/caregivers on oral care and its importance.  Oral care is a great tool for patients that refuse an NPO status or for patients that are not compliant with diet recommendations.  It’s an absolute essential for everyone.

Have you been looking for a handout for your patients about oral care?   You can download one here!  

Are you ready for a deeper dive with even more resources available? Join the Dysphagia Skills Accelerator today. You will get so many great tools with new tools being added all the time! Click here to join now!

Have you ever wanted a way to create a more standardized protocol for your Clinical Swallow Evaluation?   Do you often forget or leave out parts of the CSE, you know, the parts that are important for your Plan of Care?  You probably need the Clinical Dysphagia Assessment Toolkit if you answered yes. You can get your copy here.  

References:

Yoneyama, T., Yoshida, M., Ohrui, T., Mukaiyama, H., Okamoto, H., Hoshiba, K., … & Mizuno, Y. (2002). Oral care reduces pneumonia in older patients in nursing homes. Journal of the American Geriatrics Society, 50(3), 430-433.

Grap, M. J., Munro, C. L., Ashtiani, B., & Bryant, S. (2003). Oral care interventions in critical care: frequency and documentation. American Journal of Critical Care, 12(2), 113-118.

Yoneyama, T., Yoshida, M., Matsui, T., & Sasaki, H. (1999). Oral care and pneumonia. The Lancet, 354(9177), 515.

Abidia, R. F. (2007). Oral care in the intensive care unit: a review. J Contemp Dent Pract, 8(1), 76-82.

Langmore, S. E., Terpenning, M. S., Schork, A., Chen, Y., Murray, J. T., Lopatin, D., & Loesche, W. J. (1998). Predictors of aspiration pneumonia: how important is dysphagia?. Dysphagia, 13(2), 69-81. 

Gomes, G. F., Pisani, J. C., Macedo, E. D., & Campos, A. C. (2003). The nasogastric feeding tube as a risk factor for aspiration and aspiration pneumonia. Current Opinion in Clinical Nutrition & Metabolic Care, 6(3), 327-333. 

Seedat, J., & Penn, C. (2016). Implementing oral care to reduce aspiration pneumonia amongst patients with dysphagia in a South African setting. South African Journal of Communication Disorders, 63(1), 1-11.

Watando, A., Ebihara, S., Ebihara, T., Okazaki, T., Takahashi, H., Asada, M., & Sasaki, H. (2004). Daily oral care and cough reflex sensitivity in elderly nursing home patients. Chest, 126(4), 1066-1070. 

Tada, A., & Miura, H. (2012). Prevention of aspiration pneumonia (AP) with oral care. Archives of gerontology and geriatrics, 55(1), 16-21.