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Oropharyngeal dysphagia is a disorder that impairs a person’s ability to swallow and can lead to serious consequences, including aspiration pneumonia, malnutrition, dehydration, choking, and death.

Speech language pathologists (SLPs) have extensive knowledge regarding dysphagia and play a central role in the assessment and treatment of the disorder. Despite the high occurrence of aspiration pneumonia in patients with dysphagia, it is often considered to be a potentially preventable complication. Effective oral care has been widely accepted as a crucial component in the reduction of aspiration pneumonia, but still, it is often overlooked.

SLPs working in skilled nursing facilities (SNFs) routinely work with staff on improving patient outcomes and managing dysphagia. Consider the following true patient story that demonstrates the relationship between poor oral care and aspiration pneumonia.

Following an acute stroke, Mr. Smith was admitted to a SNF for rehab. After only a week’s stay, he

requested to be transferred to another facility, as he was unhappy with the care he had been receiving.

Upon arrival to the new facility, Mr. Smith could barely communicate his request for ice chips; the thick buildup coating his mouth had restricted his tongue, making his speech unintelligible. According to Mr. Smith, he had not received oral care a single time during his week in rehabilitation. It took 45 minutes and three health care professionals to remove the debris from his mouth. Immediately following, a clear and

completely intelligible, “Thank you, they let it get really bad,” was heard.

Unfortunately for Mr. Smith, the bacteria that had been building up over this time likely contributed to the respiratory decline that soon followed.

The next day his respiratory condition was evidently compromised and a STAT chest X-ray was ordered, which revealed right lower lobe infiltrates (indicative of aspiration pneumonia).

Despite medical intervention and administering antibiotics immediately, he was ultimately readmitted to the hospital with respiratory failure.

Unfortunately, Mr. Smith’s story is a common one, as it has been well established that dysphagia is an independent risk factor for aspiration pneumonia and a leading cause of hospital readmissions.

It has also been suggested that aspiration pneumonia is underdiagnosed, according to a 2013 article published in The Journals of Gerontology. The same study looked at the risk of hospital readmission for dysphagia patients and found staggering results, including: approximately an 80 percent increased risk of being readmitted for pneumonia, a 40 percent increased risk of being readmitted for non-aspiration pneumonia, and 400 percent increased risk of being readmitted for aspiration pneumonia or bronchoaspiration.

Patients with dysphagia are less likely to be discharged home from the hospital and instead need rehabilitation facilities, SNFs, and long term care, according to the American Journal of Alzheimer’s Disease & Other Dementias.

The prevalence of dysphagia is significantly higher in SNFs, and these patients are at a higher risk of developing complications ultimately resulting in their readmission to the hospital. In addition, many complications may be preventable.

First, it is important to understand how aspiration pneumonia occurs. A common consequence of dysphagia is material (food, liquids, saliva, vomit) entering the airway; this is termed aspiration. If the aspirated material includes gram-negative microorganisms, or “bad bacteria,” which is then introduced into the lower respiratory system, it can result in pneumonia. An individual with a compromised immune system is even more likely for an aspiration event to result in pneumonia.

Those who are immunocompromised also commonly present with decreased salivary production and/or changes in the saliva composition, which can accelerate the process of healthy oral bacteria turning into the harmful gram-negative bacteria. When these conditions are compounded by poor oral hygiene, there is a substantially greater risk of bacteria multiplying and increasing the inclusion rate per aspiration, as the bacteria is known to attach to and multiply on the oral plaques.

Once it is understood that critically ill patients are at a higher risk of gram-negative bacteria overgrowth, it is easy to understand how stopping the infection before it starts will yield improved outcomes.

Being proactive instead of reactive with good infection prevention can be the difference between a patient needing a hospital readmission or not. Decreasing harmful bacteria with an effective oral care program is not only simple to understand and implement, but it could also ultimately save patients from a costly hospital readmission and having to endure aspiration pneumonia.

Historically, nurses have reported that they believe oral care is a low priority comfort measure and is not a medical necessity. Some are fearful in providing oral care to patients with dysphagia, as they are concerned the patient will aspirate. A 2007 study in the American Journal of Critical Care reported that in regards to brushing their patient’s teeth, 33 percent of nurses interviewed reported brushing their patient’s teeth “rarely or not at all.”

Many do not understand the relationship between aspiration with poor oral care and pneumonia, and often times oral care, if and when provided, is ineffective.

Like so many dysphagia patients, Mr. Smith was no longer physically able to provide his own oral care. When asked why he did not request help from the nursing staff he said, “I did. I think they were scared.” Still, many ill patients are physically able to provide their own oral care, but may feel fatigued, lack the desire, or have a limited understanding of the critical importance in oral care.

Effective oral care with a toothbrush can prevent the overgrowth of harmful bacteria. It also stimulates saliva flow and potentially stops the disruption of an ecosystem. The movement to improve oral care programs has been successful in decreasing the risk of aspiration pneumonia in many acute intensive care unit hospital settings with ventilator-dependent patients, but there is a need for these procedures to be adopted across other settings, including post-acute and long term care facilities.

Once adequate oral hygiene is established, the SLP will more readily be able to safely recommend a diet without concern for a buildup of harmful bacteria. With decreased salivary flow, patients lose the many benefits and immune protection that saliva naturally provides. However, keeping the mouth moist by maintaining oral intake should increase salivary production and turnover in order to reduce the prospect of the bad flora sticking to the plaque and oral surfaces. Offering more palatable thickened liquids (thickened with xanthan gum) should improve quality of life and lead to increased intake, aiding in the maintenance and production of saliva needed to sustain the healthy oral ecosystem, according to a 2001 article published in the Annals of Periodontology.

The first step includes a multidisciplinary approach with the focus on education. According to a 2013 article in the Journal of Continuing Education in Nursing, once nurses understand that oral care is a medical necessity that can prevent aspiration pneumonia, they are more likely to implement effective oral care techniques.

Jennifer Maher, MA, CCC-SLP, is a senior clinician and New York City regional manager with Language Fundamentals, a provider of speech therapy services for skilled nursing facilities and a member of the New York State Health Facilities Association. Language Fundamentals is compensated by Kent Precision Foods Group, producers of the Thick-It® brand family of products, for their research and industry insights.