Abstract
During the COVID-19 pandemic in Japan, special nursing home staff often requested that home-visit dental treatment be discontinued. Even after the pandemic was recategorized as a class five infectious disease, infection control measures persisted in these homes. This case report presents treatment at a special nursing home where visiting dental care is restricted as an infection control measure. A 90-year-old woman in one of the homes refused to wear dentures, even after becoming infected with COVID-19, and sought care after a near-choking incident involving a sweet red bean bun. Although only five roots remained in the oral cavity, the food texture was unsuitable for gum mastication. Because the patient’s refusal to wear dentures was thought to be due to impaired cognitive function, forgoing dentures and dietary modification to reduce the risk of choking were recommended. Due to wet phlegm accumulation in the oral cavity, the patient was also instructed on oral care methods to prevent aspiration pneumonia, and oral hygiene management was implemented. As a result, the patient no longer had wet phlegm but refused to wear the dentures. We instructed the facility staff to continue the changed dysphagia diet. This report presents the efficacy of medical-care coordination for home-visit dental treatment, within the limitations of emerging infectious diseases.
Introduction
The relationship between periodontal disease and aspiration pneumonia is well known. Bui et al.1) demonstrated that respiratory pathogens isolated from the same patients’ dental plaque and bronchoalveolar fluid were genetically identical. A review2) indicated that the dissemination of periodontal bacteria into the lungs could aggravate age-related senescent cell accumulation and facilitate more efficient severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cell attachment and replication. Furthermore, SARS-CoV-2 can independently replicate in the oral cavity in epithelial cells and salivary glands3). Therefore, oral care for older adults is essential even under COVID-19 infection. COVID-19 became a pandemic a few months after the first case was reported in Wuhan, China in December 20194). Among Japanese facilities for older adults, special nursing homes do not have full-time doctors, and their main services are to provide daily care. Visits to residents were prohibited, and frequent home-visit dental treatment was discontinued due to Japan’s declaration of a state of emergency and the incidence of infection among residents and staff. Although COVID-19 was reclassified as a category 5 infectious disease5) in May 2023, infection control measures in nursing homes remained. Home-visit dental treatment is gradually resumed, starting with emergency treatment. We present a case of a patient with COVID-19 who refused to wear dentures and nearly choked in a special nursing care facility where home-visit dental treatment is restricted.
Case
This report was approved by the Ethics Committee of Ohu University, and informed consent was obtained from the patient and family (Approval No. 380).
1. Patient Summary
Patient: A 90-year-old woman (height 135.0 cm, weight 32.0 kg, and BMI 17.56 kg/m2).
Chief complaint: Attempted choking following refusal to wear dentures.
History of present illness: two weeks ago, the patient complained of pain when wearing the denture and initiated self-removal of the denture. Subsequently, she became COVID-19 positive. After almost choking while eating a sweet red bean bun without dentures, the facility staff requested a home-visit dental appointment.
Medical history: cerebrovascular accident sequela (right incomplete paralysis, age 76), lumbar vertebra compression fracture (age 79), recurrent cerebrovascular accident (age 86).
Stage of long-term care need6): 4 (Unable to move around on their own or otherwise unable to perform their daily activities without care).
Criteria for determining the daily life independence level7): B2 (Requires some sort of care for indoor daily life, and staying in bed for most of the time but can keep a sitting position. Requires care to get on wheelchairs).
Vital signs: blood pressure, 118/76 mmHg; pulse, 72 beats/min; body temperature, 36.4°C; SpO2, 92%.
COVID-19 vaccination: 2 doses in total.
Medications: Sennoside A and B Calcium (laxative) and Tsumura-Kampo Ninjin’yoeito Extract Granules (laxative). Amlodipine besilate (antihypertensive) and Cilostazol (antiplatelet) have been suspended for several years, considering age.
2. Intraoral Findings
There were only 5 remaining roots, and the Eichner classification8) was C3 (edentulous in both upper and lower jaws). The lips were slightly dry, and the gingiva around the remaining roots was erythematous and swollen (Fig. 1). The pharynx shows wet phlegm retention. Although the patient had a complete upper and lower denture (Fig. 2), she removed it by hand or with the tongue when the caregiver attempted to place it in her mouth.
3. Diagnosis
The patient was diagnosed with dysphagia, a preparatory phase disorder associated with the inability to use dentures due to cognitive decline, which triggers pharyngeal phase disorder and inflammation around the remaining roots.
4. Treatment
The patient was counseled on discontinuing the use of dentures, diet modification, and oral care and hygiene management. Personal protective equipment (PPE) was used in compliance with COVID-19 guidelines established by the facility, ensuring both patient and staff safety. Dentists wore PPE when entering the living room, which was disposed of at the end of the treatment according to the facility’s protocol (Fig. 3). Infection control measures were also applied to the dental instruments (Fig. 4). The dentists managed the patient’s oral hygiene using a sponge brush to remove wet phlegm (Fig. 5a, b), and continued this procedure for one month after the patient tested negative for COVID-19. The facility staff was also instructed on the provision of oral care using a sponge brush and tufted brush for the patient during the treatment period. A tuft brush was used to remove plaque around the remaining roots (Fig. 5c). SpO2 was 92% during COVID-19 positivity, but it improved to 98% upon recovery.
Fig. 4.
Infection control measures applied to dental instruments
Fig. 5.
a. Oral hygiene management, b. sponge brush to remove wet phlegm, and c. tuft brush to remove plaque around the remaining roots.
The facility staff was instructed to change the diet form of the patient from code 4 of the dysphagia diet 20219) to one level softer (code 2-2 since the code 3 is not provided in the facility) to prevent choking accidents following the discontinuation of denture use (Table 1). Although the patient no longer had wet phlegm after testing negative for COVID-19, she persistently refused to wear dentures. Hence, the facility staff was instructed to continue the dysphagia diet to prevent choking, and the home-visit dental treatment was completed. There was no infection with COVID-19 among the dentists in charge from the beginning to the end of treatment.
Table 1.Dysphagia diet provided by the facility
| Dysphagia diet |
(Regular diet) |
4 |
3 |
2-2
2-1 |
| Staple food |
Rice, soft rice |
Whole gruel |
— |
Mixer gruel |
| Main dish |
Regular and bite-sized meal |
Chopped meal |
— |
Mixer meals |
Dysphagia diet codes: 4, Not hard and sticky foods. Crushable with gums; 3, Easily mashed formed foods. Crushable with tongue. 2-2, Heterogeneous purees, pastes, and blended foods. No need to chew. 2-1, Homogeneous purees, pastes, and blended food. No need to chew.
Discussion
The patient strongly refused to wear dentures shortly before she tested positive for COVID-19 and continued to refuse even after she tested negative, suggesting that cognitive decline may have influenced her behavior. She removed the dentures after placing them in her mouth, causing her to attempt choking on a sweet red bean bun. In such cases, it is difficult to persuade the patient about the need for denture wear; hence, compensatory dietary modification that is less likely to cause choking is recommended10). Moreover, some facilities in Japan prohibit breads because they pose a high risk of choking. The patient was on dysphagia diet code 4, but because the facility did not provide code 3, her diet was changed to code 2-2. Because the patient was infected with COVID-19, no objective videoendoscopic evaluation of swallowing was performed after the change in diet. In this case, no choking or aspiration was observed after the change, which we consider an appropriate solution. On the other hand, mixer meals are added water, so even if the same amount of food is eaten as regular meals, the calorie intake would be lower. Therefore, mixer diets should be checked for weight loss due to malnutrition. Not all facilities provide all dysphagia diet codes, and the reasons for this include limited knowledge, manpower, and financial capability among food service providers. This hinders dentists’ ability to advocate for the most appropriate form of diet, emphasizing the importance of information and education regarding dysphagia diet for improved coordination with medical-care.
In addition to the implementation of oral hygiene management through home-visits, the facility staff was instructed on oral care methods. This is essential, given the decreased immunity associated with COVID-19, to prevent aspiration pneumonia sequela to oral infection. Oral health management through medical-care coordination eliminated wet phlegm and allowed the patient to recover from COVID-19 without complications of aspiration pneumonia. Because COVID-19 is transmitted through the oral cavity, proper oral hygiene is recommended for its prevention11). Alternatively, because oral care can produce aerosols, infection control measures should be taken12). Furthermore, the fact that dental care is aerosol-prone has discouraged people from visiting dentists, leading to an increase in oral diseases13). Hence, medical practitioners should educate caregivers about oral care based on the existing COVID-19 guidelines. One of the issues we need to address is infection-control-based oral care promotion in nursing homes without home-visit dental treatment. Since caregivers provide daily living care such as bathing, excretion, and eating, there are limitations in differentiated intervention infection control measures for each task, including oral care. We speculate that there are still issues to be resolved in infection control measures in anticipation of future epidemics of emerging infectious diseases.
One limitation of this case report is that its findings cannot be universally applied, as the classification of care and diet differs across countries. Descriptions of the classifications in English can be found in the relevant references.
Conclusions
We present a case of oral hygiene management, diet modification, and oral care guidelines for a patient with COVID-19 who refused to wear dentures in a special nursing care facility setting where home-visit dental treatment is restricted. Even under future public health restrictions due to emerging infectious diseases, it is important to consider the need for interdisciplinary collaboration and education of caregivers for medical-care coordination in the treatment of dysphagia in geriatric facilities.
Acknowledgments
We would like to thank the facility staff for their cooperation during the home-visit dental treatment.
Conflict of Interest
The authors declare no conflicts of interest.
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