Oral Cares For Days

SLP colleague and #SLPeeps twitter friend Rachel Wynn recently rallied the community of SLP bloggers to write about research. The mission? Taking the time once a month to read a research article and then write a review about it.

Having recently attended ASHA’s Dysphagia in Older Adults online conference, I have had a lot of research on my mind. As with any good continuing education, I walked away from the conference with far more questions than I had when I started it. Since then, I have found myself thinking often about different presentation topics, and how they fit into my professional life.

One topic that stands out to me, in particular, is that there is a lack of adequate research in acute care. And it seems that my conference wasn’t the only one during which this topic arose.

I’m finding myself in an interesting position, profesionally speaking. It has been now two years since I earned my CCCs, and at the moment I feel like all I want to do is pause, pull out all my textbooks and notes, and re-learn everything I ever studied in school. My perspective has shifted so significantly since I was a student; I find myself thinking about everything on a much larger scale than I ever imagined, and there’s so much I want to know.

Having a goal in mind is always nice, so it was timely that Rachel suggested this blogging endeavor. It’s given me a little bit of direction, something I think I sorely needed.

An Article: Nay, a Review

One of the presentations from the online conference was called Oral Hygiene in Older Adults: Complications, Assessment, and Care, and was presented by John R. Ashford, PhD, CCC-SLP. In 2012, I joined two Special Interest Groups, and when looking for articles for this project, I happened to perusing the “Perspectives” resources for SIG 13 (Swallowing and Swallowing Disorders). John Ashford had published an article in 2012 called Oral Care Across Ages: A Review.

Personal Bias

As an acute care SLP, I find that many of the patients I work with have, for lack of a better descriptor, disgusting mouths. This could be do to any number of factors: alcohol or drug abuse, prolonged intubation, and radiation therapy for cancer, to name just a few. When I work in the ICU, I have a tendency to start working with patients early. That is, I like to evaluate them before they might be ready to start eating. Not only have I found it beneficial in terms of being able to really gauge patients’ progress, but it also allows me to do my part to help advance them to feeding readiness.

I can’t quite recall when I started to say it, but I noticed recently that I have a little catch phrase I seem fond of sharing with patients and families: “If your mouth doesn’t feel good, then the rest of you doesn’t feel good.” It’s a simple observation, but I feel it’s a powerful one. It occurred to me at one point when I was sick; the combination of mouth-breathing and that filmy yet dry coating of my tongue and palate seemed to compound my illness.

The Mouth At Work

How does the mouth really work? It turns out, it’s not all that different from the rest of our GI tract. We’re very fond of probiotics these days, and we often discuss the idea that within our bodies lies a veritable ecosystem of bacteria. Our oral cavity, as the “beginning” of our GI tract, has its own ecosystem. John Ashford breaks it down nicely: “the oral cavity is covered by a protective mucous membrane, serous fluids, and mixtures of microorganisms, or flora, comprised of bacteria, viruses, and fungal species.”

The fancy term for this is biofilm, and it covers the surfaces of the oropharynx and teeth. “These coatings benefit the oropharynx by stimulating the immune system to protect surfaces against colonization and infection from invading microbes and to stimulate certain nutritional and digestive functions.” It’s like a naturally-occurring vaccine: a little bit of exposure keeps our immune system on the ball. The flora also function, as they do in our intestines, to help break down nutrients so that our bodies can extract them and use them accordingly.

Breakdown

While we are able to manage exposure to bacteria when healthy, illness of any kind leads to susceptibility. Poor oral health coupled with illness can leave one with greater colonization of bacteria and fungi, which, if aspirated, has the potential to cause pneumonia.

Many of the patients I encounter have poor oral care at baseline, which results in lost and broken teeth, and many of them have full or partial dentures. “[T]he acrylic and silicone materials used in denture and denture-lining construction provide ample surfaces for bacterial attachment.” As a result, proper denture cleaning is a must in addition to oral cares. Another point to consider, which I hadn’t before, is that “dentures that fit closely to mouth surfaces reduce salivary cleaning” (emphasis mine). We swallow routinely throughout the day, so basically the flora in our mouths are not permanent residents.

In his presentation for the Dysphagia in Older Adults Conference, John Ashford explained that saliva contains certain sugars, and it is those sugars (rather than oxygen) which the pathogens in our flora live on. Saliva, in a sense, acts as both an incubator (maintainer of moisture to provide an environment for flora to thrive, relatively speaking) and a lubricant. The “serous fluid [found in saliva] is rich in antimicrobial substances… [which prevent oral pathogens] from attaching to and colonizing the oropharyngeal surfaces, thus preventing oral infections.”

Oral Cares

Where does this leave us as SLPs? There are different schools of thought: some feel that oral cares responsibility lays with nurses and techs. It makes sense, given that they are usually the ones present 24/7, while we SLPs can only be present intermittently. Any SLP who has worked in a medical setting, be it acute, LTAC, SNF, etc., is likely aware that oral cares are often neglected in the face of other, seeming more pressing, issues. I’ve also found that my emphasis and perspective of the importance of good oral care is not always shared by others; this isn’t a bad thing, necessarily, but I think the nature of increasing specialization. It’s why being part of an inter-disciplinary team is so important: I can develop a plan, emphasize its importance, and encourage the team to follow the plan to ensure the best patient care.

Ashford cites a number of studies which show that “tooth brushing is strongly supported over use of foam swabs with hospitalized and nursing care patients”, as “toothbrushes were substantially better at removing plaque”. When I provide oral cares, I often begin with a swab, as I have found it more effective to remove dry oral mucosa that may be coating the tongue, teeth, and palate. Once I am able to clear the oral cavity, I then go back to brush properly. In the event that someone’s mouth is particularly messy, I like to provide thorough cleaning before initiating any PO trials. It has the benefit of not only helping the patient feel better (and optimize their chances for success), but it can also serve as a nice way to increase level of arousal in somnolent patients.

Moving Forward

I appreciated this article, as well as the conference lecture, as an excellent starting point. I have been looking into further into tools like the Oral Health Assessment Tool (OHAT) and educational tools like “KISS” (Keep it simple, staff) Basic Oral Care for caregivers.

I hope to increase my knowledge and plan to implement oral care plans as part of my recommendations. I hope to help my department increase awareness of the importance of oral care and how it can benefit patients. I hope to increase the availability of artificial salivas (such as Mouth Kote) for critically ill patients suffering from xerostomia.

I would also love to start collecting more informal data so that I can monitor patient progress compare efficacy of the treatments I may provide.

As I wrap up this post, I’m struck by how much I still want to know. Many of the resources Ashford provided in his article are from outside professions, such as dentistry and other medical publications. I am reminded that, while we have wonderful resources available within our own organization, sometimes collaboration with other professions can yield a whole other world of applicable information.

I look forward to continuing to explore new territory. I hope to keep finding reasons to question what I know, and to always work to broaden my horizons.

Article Citation: Ashford, John. (March 2012.) Oral Care Across Ages: A Review. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), vol. 21, pp. 3-8.

(Aside: Comments are open. I welcome dialogue, new ideas, and cool ways to rethink all these things. Thoughts?)