[Purpose] In neuromuscular diseases (NMD), dysphagia progresses under their recognition, resulting in severe respiratory complications, such as choking or aspiration pneumonia. In this study, we investigated the levels of nutrition before and after admission to a hospital, and after videoendoscopic evaluation of swallowing (VE) in NMD, and the factors associated with nutrition level after the VE.
[Methods] The subjects were 25 patients with NMD. We retrospectively investigated them by questionnaires, bedside evaluation sheets, and VE evaluation sheets. The levels of nutrition before and after admission to a hospital, and after the VE evaluation, were scored with the Functional Oral Intake Scale (FOIS-before, FOIS-after, FOIS-VE, respectively). We compared those FOIS scores, and tested which factors in the evaluation sheets were associated with the FOIS-VE.
[Results] Pneumonia or fever, and appetite loss were the top reasons for admission. The FOIS-after and FOIS-VE were significantly less than FOIS-before (p＜0.05). The FOIS-VE was significantly correlated with “food residue”, “voluntary cough”, and “wet hoarseness” in the bedside evaluation sheets, and “saliva retention” in the VE evaluation sheets.
[Conclusion] The present study demonstrated that the nutrition level in NMD patients significantly decreased through hospital admission. The findings in this study indicate that screening tests and oropharyngeal evaluations at adequate timings are needed to prevent severe complications. The factors associated with FOIS-VE could be indicators to identify inadequate nutrition levels.
An investigation was performed with regard to an optimum citric acid concentration for a cough test using a cough threshold for patients with dysphagia accompanying a primary disease.
The subjects of the investigation were 94 patients suspected of having dysphagia, aged from 21 to 92 years old (male: 64, female: 30, average age: 66 ± 13 years old), all of whom underwent Videoendoscopy (VE) or Videofluorography (VF), and also a cough test .
The patients inhaled a citric acid isotonic sodium chloride solution from a supersonic wave nebulizer for 1 min, and any resulting coughing was observed. The concentration was set so that coughing could be observed at least five times in a 1 min period of time, with a cough threshold of the subject being determined. If coughing occurred four times or less, the citric acid concentration was increased until coughing occurred five times, so that the cough test could be performed. The concentrations of citric acid used were 0.25, 0.5, 1.0, 2.0, 4.0 and 8.0%. The specificity and sensitivity of the screening of silent aspiration (SA) were obtained from this data and an ROC curve was drawn up.
As a result of the VE/VF, the group with no aspiration or laryngeal penetration (no aspiration group) contained 43 patients, the aspiration group 30 patients, and the SA group 21 patients.
From this, the average of the overall cough threshold was 1.55±1.44%, and the cough thresholds from the results of the VE/VF were 1.26±1.25% in the no aspiration group, 1.21±1.03% in the aspiration group and 2.63 ± 1.78% in the SA group. Significant differences were found between the no aspiration group and the SA group, and between the aspiration group and the SA group.
The optimum citric acid concentration for the cough test was examined for the screening of SA, and as a result 1.0% was found to be the most suitable concentration. It was also revealed that the cough threshold of the SA group was significantly elevated in comparison with the thresholds of the no aspiration group and the aspiration group.
[Purpose] In the acute stage of stroke, risk management, including the prevention of disuse syndrome and complications such as pneumonia, is necessary. Systematic and comprehensive dysphagia rehabilitation is also necessary in order to quickly acquire an oral intake ability and subsequent self-care ability. In this study, we examined the effectiveness of a dysphagia rehabilitation program which had been performed since fiscal 2007, with the goal of carrying out an effective program for acute stroke patients.
[Method] This study included 367 acute stroke patients (223 males and 144 females; mean age: 71±12.8), who underwent eating function therapy between April 2006 and March 2009. The characteristics of the subjects and the results of dysphagia rehabilitation (number of subjects who switched from tube feeding to oral intake, number of days from admission to the beginning of dysphagia rehabilitation, number of days from admission to oral intake, incidence of pneumonia during hospitalization, swallowing ability grade score at discharge, mean length of stay) were compared for each fiscal year. The changes before and after program implementation and all influencing factors were also examined. The statistical analyses were performed using SPSS for Windows 13, and the statistical significance level was set to less than 5%.
[Results] The number of subjects who switched to oral intake increased after the program (93.4% in fiscal 2007 and 2008) as compared to that before the program (83.1% in fiscal 2006). The length of hospitalization until oral intake decreased after the program (6.8 days vs. 14 days). The incidence of pneumonia during hospitalization also decreased after the program (2.8% vs. 13%). The swallowing ability grade score at discharge improved after the program (8.8 vs. 7.6), and the patients who could eat ordinary meals at discharge increased. A logistic regression analysis revealed that the program decreased the incidence of pneumonia during hospitalization, and improved the swallowing ability grade at discharge.
[Conclusion] In the acute stage of stroke, dysphagia rehabilitation carried out according to the comprehensive program from the first day of hospitalization facilitates the reacquisition of oral intake ability. It also prevents pneumonia and improves the swallowing ability function at discharge.
A prosthetic approach that aims to improve swallowing function has been used recently, although there are no criteria for indication and methods for using it. Therefore, we conducted an investigation to verify the effectiveness of palatal augmentation prosthesis (PAP) which is commonly used for patients with dysphagia. A prospective cohort study was conducted that compared the effect of dysphagia training with or without PAP. The first evaluation was performed after two weeks from the first examination for 74 patients in the PAP group, and then training with PAP was performed. The second evaluation was done 2 weeks after the first evaluation. The schedule of the first and second evaluations was the same for the 68 patients in the without-PAP group. We found the indication depended on tongue movement or dysarthria rather than the primary disease. Swallowing reflex, pharyngeal residue and dysarthria were improved in the dysphagia patients with tongue dysfunction and the improvement was significantly larger in the PAP group than in the without-PAP group. Oral intake improves patients’ lives, such as patients begin to want to go out, or have more opportunity to have conversation. PAP is useful, but merely a supportive apparatus and compensative approach. Therefore, we must recognize that continuous exercise is important to improve paralyzed function.
The present study used as an ingredient a commercial powdered food, which turns into gel-type blender gruel when stirred after the addition of hot water, to prepare samples. Different stirring conditions were used to prepare different samples. For each sample, the textural properties were measured as the physical properties, the physical properties were simply evaluated through the glass ring method, and the correlations with the results of “ease-of-eating” obtained from sensory evaluation were examined. When the samples using powdered gel-type blender gruel were heated (with the addition of hot water) and stirred frequently for preparation, the gel structure was inhibited. These samples turned soft, both at sample temperatures of 45℃ and 20℃. Meanwhile, the adhesiveness was affected to different degrees by the stirring frequency, depending on the temperature to which the samples had been heated during preparation. The measurements using the glass ring method revealed that samples that were stirred more frequently during preparation demonstrated larger spreading coefficient and weight of adhering to the glass ring used for measurement. Hence, the gel-type blender gruel samples possessing those characteristics were evaluated to be soft, sticky, and relatively hard to swallow. These results suggest that the ease-of-eating of gel-type food (within a hardness range of 1×103 to 1.5×104 N/m2) can be inferred by the glass ring method of measurement. Taking into account the results of the present study, which demonstrated differences in the correlation between the adhesiveness of textural properties and the stickiness obtained from sensory evaluation depending on the sample temperature, the authors confirmed the necessity of developing a method of measuring the textural property of adhesiveness that can appropriately indicate the “easeof-eating”of samples.
Oral care provided during the perioperative period has beneficial effects on ventilator associated pneumonia and surgical site infection, and is recommended for surgical patients. Reduction of oral bacteria is considered to be an important factor to prevent infectious complications, but the immune function and nutritional condition also appear to be involved in such prevention. In this study, it was hypothesized that the immune function is also responsible for the mechanism of the effect of oral care. We evaluated the number of oral bacteria, and NK cell activity levels, adopted as an index of the immune function.
The study subjects consisted of 36 patients undergoing surgery for gastroenterological cancer. They were assigned to a control group (patients themselves or care workers were involved in oral hygiene as before) or an oral care group (dentists provided oral care once before admission, and primarily once a day on days 2 through 6 postoperatively). The number of oral bacteria, NK cell activity levels, and prealbumin levels were evaluated.
As a result, the number of oral bacteria in the control group was larger on day 7 postoperatively than before surgery, whereas that in the oral care group did not increase. NK cell activity levels in the control group were lower on day 7 postoperatively than before surgery, but that in the oral care group could be maintained. Prealbumin levels markedly decreased in both groups.
In gastroenterological cancer patients with severe postoperative wasting, in whom autopurification was not likely to function, we could inhibit the growth of oral bacteria through oral care provided by dentists during the perioperative period. Also, NK cell activity could be maintained, possibly due to the influence of social support on immune function.
It is desirable to disseminate oral care for perioperative patients with gastroenterological cancer.
The Health Care Management System during Large-scale Disasters is being regulated, and so is the Dental Health Care Management System. However, it still is difficult to correspond to intractable diseases. The current status of the management system for dysphagia patients was surveyed in each dental healthcare system, and future tasks to discuss in proposed systems, since it is expected to manage dysphagia patients with an older population.
Possible aid for dysphagia patients is not only dental treatments, but also tests for dysphagia function, food instruction, and oral care, but which was not available at that time. However, 60% of them acknowledged the need. A proposed system which cooperates a dentists association and a hospital dental clinic, were accepted in some dental schools but not in clinics. The answers varied from hospital dental clinics and dentists associations.
Dysphagia functions and disorders are not treated just in dental fields. Even if functional tests of dysphagia are possible, there are problems how to serve reasonable food to feed. It is necessary to establish manuals and guidelines including regional cooperation aid systems of public services and dentists associations, such as above. In conclusion, it is urged to implement a multi-disciplinary education seminar, and information sharing.
[Introduction] Marchiafava-Bignami disease (MBD) is a unique disorder caused by alcohol abuse or malnutrition with symptoms such as disturbance of consciousness and convulsion due to lesions in the corpus callosum. Here we report a case where a patient with MBD achieved a full transition from nasogastric tube to oral feeding through swallowing and dysphagia rehabilitation.
[Case] A 46-year-old woman was transported to a hospital by ambulance due to disturbance of consciousness. Magnetic resonance images of the brain revealed areas of high signal intensity in the corpus callosum. She was diagnosed with MBD given a history of alcohol abuse. Detailed testing of feeding and swallowing functions was initiated upon her transfer to another hospital 2 months after the onset.
[Treatment course] Irritation symptoms and impaired orofacial function were observed. Video-endoscopy (VE) of the pharynx during deglutition revealed pharyngeal contamination. Tube feeding was continued while the patient underwent indirect training, which included orofacial function training and oral care. VE confirmed the absence of aspiration. Direct training was initiated once the patient was able to ingest jelly with some assistance. Food was gradually transitioned from jelly to mashed foods based on re-evaluations. She was eventually able to revert to oral feeding; no aspiration pneumonia developed. With the improvement in feeding and swallowing functions, Functional Independence Measure scores that represent independence level of patient also improved in both cognition and mobility categories.
[Conclusion] Comprehensive rehabilitation aimed at improving oral feeding performance led to improvements in ADL as well as feeding and swallowing functions in a patient with MBD. Feeding and swallowing impairments must not be overlooked during the course of MBD treatment. Our findings suggest that patient outcomes can be improved by responding appropriately to these impairments.
Oral drug selection is important for patients with dysphagia. We report a case of a patient suffered from an ulcer caused by residual drugs in the oral cavity.
[Case] An 89-year-old female with dementia with a history of hypertension and cerebral infarction was admitted for pneumonia, respiratory insufficiency, and dysphagia. Before admission she used a wheelchair, and had taken a normal diet. After admission she ate mixer-processed dysphagia diet 3 times a day with assistance but sometimes choked.
[Course] At 1 month after admission, a nurse reported oral hemorrhage to the dental department. The oral cavity was edentulous and dry. The mucosal color had changed to yellowish green in the right buccal over the sublingual mucosa and the right lips. And ulceration and hemorrhage were noted in the central region.
The cause was unclear at that time, but a dental hygienist continuously performed oral care and the condition improved. However, the same findings were observed in the left buccal over the sublingual mucosa 5 days after oral care initiation. A residual drug (Fero-gradumet tablet®) was found in the region, suggesting ulceration caused by the residual drug. Since no problem was noted on a modified water swallowing test on admission, the respiratory department recommended oral drug ingestion with water after meals. Thus, the dental hygienist requested the nurse to confirm the absence of any residual drug in the mouth after drug ingestion. However, the retention of a drug (Pletaal®) in the palatal region was noted after 2 days. After discussion with nursing staff, the administration method was changed to the ingestion of a jellyembedded drug. No problem occurred thereafter. The ulcer had completely healed with the above oral care after 20 days.
[Discussion] The oral retention of drugs is problematic. Because such residual drugs injure the mucosa, as noted in the present patient, and a necessary amount of the drug is not absorbed. The important role of dental hygienists includes not only oral care, but also the discovery of drugs retained in the oral cavity, as well as the proposal of an appropriate drug administration method.
[Purpose] Expiratory muscle training (EMT) has been attempted to prevent aspiration pneumonia in recent years. Some researchers reported that EMT was effective for a cough and swallow function. However, there have been very few reports on the effect of EMT for a swallow function. This study was conducted in a single case. The purpose of this study was to observe respiratory, oral and swallow functions through EMT in a single patient.
[Subject] A patient was a 64-year-old man with Parkinson's disease. He had received nursing care insurance services at home. He was at stage Ⅲ in the Hoehn and Yahr scale and partially dependent on activities of daily living. His cognitive function was normal.
[Method] This study design was A-B-A. This training was not under supervision. The protocol was 15 min twice a day for 4 weeks in the B period. The expiratory threshold of EMT was set at 30% of the maximum expiratory pressure by the reverse use of Threshold IMT. This pressure was measured and the threshold was adjusted every week. We measured respiratory and cough functions by spirometer, and respiratory muscle strength by a pressure meter at an interval of a week. In addition, we measured oral and swallow functions by questionnaire at the first and last timing of B.
[Results] The respiratory function showed an increase of the peak expiratory flow and cough flow. The respiratory muscle strength showed an increase of the maximum expiratory and inspiratory pressure. His RSST was improved by three to four times. His labial closing strength was increased by 4.82 to 5.61 Newton. His dysphagia, choking, air-leakage from his lips in closing his mouth improved in some questionnaire items.
[Conclusion] EMT was affected not only respiratory function, respiratory muscle strength, and oral function, but a swallow function for a single case in this study. This intervention was acceptable for the elderly and may have a possibility to prevent aspiration pneumonia by improved swallowing. Further investigation is necessary to identify the effect of EMT for swallow function.