Background and Objective: Patients with cancer associated with recurrent stomatitis and patients who undergo hematopoietic stem cell transplantation are required to clean their oral mucosa using an oral swab, as an important infection control measure. An oral swab should be used as a disposable device in consideration of hygiene, but may sometimes be used several times in clinical settings. The aim of this study was to identify the number of bacteria adhering to oral swabs after use and to evaluate the effects of washing and drying and differences in the materials of oral swabs on the number of adhesive bacteria, with the overall goal of understanding the bacterial contamination status.
Materials and Methods: (1) Number of adhesive bacteria after single use of two oral swabs: Nine healthy subjects (aged 20–60 years old) were provided with two oral swabs and instructed to wipe the oral mucosa for 1 min. Then, the number of bacteria adhered to these oral swabs (Log CFU) were counted using a culture method.
(2) The oral swab was collected after use to evaluate and compare the effects of washing methods (water in a glass, running water), the presence or absence of squeezing, surface roughness of the oral swab, and drying time on the number of bacteria adhering to the oral swab.
(3) The bacterial species detected after washing and drying of the oral swab were isolated for Gram staining and hemolysis and to observe the morphology.
Results: The median number of adhesive bacteria on two oral swabs immediately after use (Log CFU) were 8.09±0.55 (minimum: 7.75, maximum: 9.29), 8.54±0.52 (minimum: 7.86, maximum: 9.34), respectively. There was no significant differences between two oral swabs.
The number of bacteria adhered to the oral swab after use decreased significantly after washing with running water compared to water in a glass and after squeezing compared to omission of squeezing. The texture of the oral swab did not decrease the number of adhesive bacteria after washing and drying. Bacteria were detected even after the oral swab was dried for 72 h at 37℃. All isolated species were Grampositive cocci, coccobacilli or bacilli, except for one Gram-negative bacterium.
Conclusion: Some washing and storing conditions decreased the number of bacteria adhered to an oral swab after use, but it was difficult to completely remove all bacteria. Reuse of an oral swab increases the risk of infection and should not be permitted.
Stroke is a major etiological factor in dysphagia. The purpose of this study was to investigate the factors affecting difficulty of oral intake in patients with cerebrovascular disorders.
Two hundred and fourteen stroke patients with stroke-related dysphagia who entered an emergency hospital between March 2009 and March 2010 were recruited. Multivariate analyses were performed to identify variables significantly associated with the possibility of oral intake.
The mean age of the patients was 75.4 (SD 12.4) years. A total of 93 patients suffered from ischemic stroke while 34 suffered from hemorrhagic stroke. At the point of discharge from the hospital, 85 patients (66.9%) resumed a regular diet. Logistic regression analysis identified four factors that significantly predicted the resumption of oral intake: a lesion limited in the right hemisphere; a score＞0 on the Barthel Index; normal swallowing sound in cervical auscultation; a profile score of 4 or above in the food test. The sensitivity and specificity of the forecast type that attained oral intake were 84.7% and 66.7%, respectively. The probability of attaining oral intake was 99.8% when all five factors were excellent values, but was 31.9% when all five factors were disadvantageous.
These findings suggest that for patients with stroke-related dysphagia, the feeding tube should be removed and oral intake attained before discharge.
Purpose: Tongue movement in swallowing plays an important role in bolus formation and lingual bolus propulsion. Recently, tongue pressure is noted as one of the factors of tongue motor function and swallowing function. The purpose of this study was to investigate the relationship between tongue pressure and swallowing function in dysphagic patients and healthy volunteers.
Subjects and Methods: The subjects comprised 107 healthy volunteers and 66 dysphagic patients. We evaluated tongue pressure using the JMS tongue pressure measuring instrument for all cases. Healthy volunteers were investigated in terms of gender and age, and dysphagic patients were evaluated on the dysphagia severity scale (DSS), eating status scale (ESS), and functional oral intake scale (FOIS). We also conducted a videofluoroscopic examination of swallowing (VF) findings.
Results: Maximum tongue pressure of male subjects was larger than that of female subjects in healthy volunteers (p＜0.01), and there was a correlation between maximum tongue pressure of males and age (r＝－0.30). However, tongue pressure during swallowing did not significantly differ with gender and age. There was a significant correlation between maximum tongue pressure and DSS, ESS, FOIS in dysphagic patients (r＝0.33–0.58). Maximum tongue pressure showed a significant correlation with oral cavity residue, bolus formation, lingual bolus propulsion, and vallecular residue in VF findings (r＝0.51–0.82). Tongue pressure during swallowing also showed a significant correlation with oral cavity residue, bolus formation, lingual bolus propulsion, and vallecular residue (r＝0.45–0.75). There was a weak correlation with piriform sinus residue.
Discussion: By evaluating tongue pressure, it is possible to measure tongue motor function easily and quantitatively. Tongue pressure reflects the severity of dysphagia, and could be used to determine diet for dysphagia patients. Furthermore, tongue pressure showed a significant correlation with the tongue motor functions of bolus formation and vallecular residue in VF findings. This study suggested that tongue pressure influences the lingual and pharyngeal phase of swallowing. In addition, tongue pressure exercises may be useful in preventing and improving swallowing function in the lingual and pharyngeal phase.
Purpose: The aim of this study was to determine the incidence and pathophysiology of dysphagia associated with an atypical antipsychotic drug administered for sedation.
Subjects: From July 2010 to June 2011, 69 hospitalized patients, who were being treated for unrest and excitement during their stay, were given an atypical antipsychotic drug.
Patients with psychiatric disorders or central nervous system diseases were excluded from the study.
Methods: Risperidone (0.5 or 1 mg) was administered to all 69 patients. After administration of the drug, we sequentially evaluated the deglutition status of patients using the repetitive saliva swallowing test and the modified water swallow test. Results over a 3-day period were scored using the dysphagia severity scale.
Of patients with dysphagia, the severity of extrapyramidal symptoms and daily living were rated using the Unified Parkinson’s Disease Rating Scale (UPDRS) and the Barthel Index, respectively, at the onset and time of relief of dysphagia. Patients’ swallowing abilities were further evaluated with videofluorography (VF).
Results: Thirteen of 69 patients (18.8%) developed dysphagia after receiving risperidone. Nine patients developed dysphagia after a single dose; 3 patients were affected after 2 consecutive doses; and 1 patient was affected after 3 consecutive doses of the drug. Administration of risperidone was immediately stopped when dysphagia occurred. The VF showed prolongation of oral transit time of the alimentary bolus, a delay in onset of the swallowing reflex, and reduced anterior displacement of the hyoid bone during the dysphagia period. Symptoms of dysphagia lasted from 2 to 28 days.
Discussion: The incidence of risperidone-related dysphagia was higher than expected. It is noteworthy that even small amounts of risperidone (0.5 mg) gave rise to dysphagia, resulting in prolonged symptoms in some cases. The VF revealed that risperidone affected both movement and perception associated with deglutition.
Patients receiving atypical antipsychotic drugs pharmacologically similar to risperidone for the treatment of unrest and excitement should be routinely monitored for the occurrence of dysphagia.
Objective: We hypothesized that the grip strength, which is regarded as an index of systemic muscle strength, and tongue pressure, which has been reported to be related to the swallowing function, reflect the strength of muscles involved in swallowing and evaluated their relationships with pharyngeal residue presence on videofluoroscopic examination of swallowing (VF) and videoendoscopic examination of swallowing (VE).
Subjects and Methods: The subjects were 38 males with dysphagia (mean age: 80.0±9.6 years) who underwent VF/VE at our hospital.
The grip strength was measured using a Smedley handgrip dynamometer, and the tongue pressure was measured using a tongue pressure meter TPM-01 (JMS Co., Ltd.). Pharyngeal residue presence was evaluated by VF/VE after swallowing a test food, which was a puree or paste with an adjusted thickness, and was rated as present or absent according to retention of the test food at the epiglottic vallecula and piriform recess.
The mean grip strength and tongue pressure were compared between those with and without a pharyngeal residue (1) in all subjects, (2) by disease (with/without brain disorders), (3) by age (＜75 / ≥ 75 years).
Results: In all subjects, the mean grip strength and tongue pressure were 22.5±9.0 kg and 21.5±7.4 kPa. The grip strength was significantly reduced in those with a residue in the piriform recess. The grip strength and tongue pressure were significantly reduced in those with a residue in the piriform recess among those with brain disorders and those aged ≥ 75 years. Between those with and without a residue in the epiglottic vallecula, no significant difference was observed in the grip strength or tongue pressure by age or disease.
Discussion: The grip strength and tongue pressure were correlated with a residue in the piriform recess depending on the disease and age. This suggests that the grip strength and tongue pressure reflect the strength of muscles involved in swallowing under particular conditions. We speculate that, in patients after internal or surgical treatments and elderly people with no brain disorders, aging, disease, and malnutrition lead to a general decrease in muscle strength due to sarcopenia, and that the weakness of muscles involved in swallowing is detected as a pharyngeal residue in a VF/VE swallowing study.
Purpose: We examined the association of a concentration of saliva protein (secretory immunoglobulin A: sIgA; lactoferrin: LF; epidermal growth factor: EGF) with age, Streptococcus pneumoniae carrying germs and pneumococcus vaccination.
Method (s): The subjects were normal adults in their thirties to fifties and local community elderly. We gathered unstimulated saliva after the measurement mucosa wettability in the tongue and buccal mucosa, and measured the sIgA, LF and EGF concentrations by enzyme-linked immunosorbent assay (ELISA). The quantity of Streptococcus pneumoniae DNA was measured by real-time polymerase chain reaction (real-time PCR).
Subjects were classified by an age factor (adult group, older adult group, old-old group), a pneumococcus vaccination factor (non-inoculation group, inoculation group), a Streptococcus pneumoniae factor (non-carrying group, carrying group), and compared the relationship with the saliva protein statistically.
Result (s): The subjects were 63 people in the adult group (mean age±SD: 46.0±7.5), 130 people in the older adult group (mean age±SD: 69.9±2.4) and 141 people in the old-old group (mean age±SD: 80.0±4.2). Streptococcus pneumoniae bacteria carriers included 35 people in the adult group (55.6%), 61 people in the older adult group (46.9%), and 46 people in the old-old group (32.6%). The concentrations of sIgA, LF were significantly higher in the old-old group than the adult and older adult groups. And the concentration of EGF was significantly higher in the older adult and old-old groups than the adult group. We compared with a pneumococcus vaccination factor, but there was no difference according to the sIgA concentration. As for non-carrying and carrying group, non-carrying were higher than those carrying in LF, and EGF concentration (p＜0.05, p＜0.01).
Conclusion: The adult group had the highest Streptococcus pneumoniae carrying germ ratio. As for the concentrations of sIgA, LF, EGF, a rise by the aging was suggested. The non-carrying group was higher than the carrying group in the LF, EGF concentrations. It was suggested that the pneumococcus vaccination does not affect the sIgA concentration and the Streptococcus pneumoniae carrying germs.
Objective: The aim of this study was to investigate the risk factors for liquid aspiration among dysphagic patients with schizophrenia.
Patients and Methods: This study was performed retrospectively and included 225 dysphagic patients with schizophrenia that were referred to the Department of Dentistry and Oral Surgery of our hospital from November, 2009 to January, 2014. In this study, there were 122 males and 103 females, and the mean age was 65.5 years (standard deviation 12.5 years). Liquid aspiration was assessed by means of videoendoscopic examination of swallowing (VE). Doses of neuroleptics at the time of VE were converted to milligram equivalents of chlorpromazine (CP equivalent dose), and the mean CP equivalent dose at the time of VE was 501 mg/day (standard deviation 584 mg). We investigated the relationship of liquid aspiration to age, sex, activity of daily living, body mass index (BMI), CP equivalent dose, orofacial dyskinesia and gag reflex by univariate analysis and multivariate analysis by using logistic regression analysis (backward selection method).
Results: The univariate analysis indicated that liquid aspiration was significantly related with the independency of daily living (p＝0.036), BMI (p＝0.022) and gag reflex (p＝0.004) whereas there were no significant relationship of the aspiration to sex, age, the independency of indoor living, sitting ability and orofacial dyskinesia. Logistic regression analysis indicated that there was significant relationship (p＝0.015) between gag reflex and the liquid aspiration whereas the relationships between the aspiration and the other 8 factors were not statistically significant.
Conclusion: Logistic regression analysis indicated that the impairment of gag reflex was significantly related with the occurrence of the liquid aspiration among dysphagic patients with schizophrenia.
Purpose: Thermal-tactile stimulation (TTS) is an indirect training method for dysphagia. Some reports have shown that TTS increases the sensitivity to induce swallowing, while others have demonstrated that the effect does not always appear. In addition, the benefit and mechanism of the effect of TTS remains to be elucidated. In this study, to investigate the effect of TTS, a frozen cold cotton swab was used as a stimulant, and the influence on latency before the swallowing reflex induced by droplets of water was examined.
Subjects and Methods: The subjects were 10 healthy young adults with no eating or swallowing problems. After saliva was swallowed, water was dropped at 1.0 ml/min to the posterior part of the back of the tongue and latency before the induction of swallowing reflex was measured five times. After a rest, TTS was performed, and latency before swallowing reflex induced by droplets of water was measured five times. Latency was compared before and after TTS.
Results: The average of the latency in 10 subjects measured before and after TTS was 13.8±6.7 s and 11.2±5.6 s, respectively, and latency was significantly reduced after TTS (p＜0.05). The average latency was 11.3±4.7 s at the first measurement, 10.7±5.1 s at the second, 11.7±6.9 s at the third, 11.2±5.8 s at the fourth, and 11.4±5.5 s at the fifth measurement (about 10 min after TTS). After TTS, the latency was significantly reduced at each measurement (p＜0.05).
Conclusions: Latency before swallowing reflex was reduced immediately after TTS, and the effect continued for at least 10 min. These results indicate that TTS hastens the beginning of the swallowing reflex and suggest that it is an effective training method for dysphagia.
Introduction: We report a case of marked inability to close the mouth and dysphagia. A devised mouthclosing exercise improved this patient’s open-mouth state and enabled oral ingestion.
Patient: An 85-year-old man with aspiration pneumonitis and dehydration was admitted to a local hospital at the end of July 201X. Although oral ingestion was resumed, he remained unable to close his mouth and had difficulty swallowing. Therefore, he was transferred to our hospital in August for swallowing training.
Clinical Course: His inability to close his mouth was evaluated with CT scans, but neither TMJ luxation nor bone fracture was detected. Paralysis of masticatory muscles was suspected. A speech therapist performed mandibular range of motion and muscle-strengthening exercises, but his open-mouth state did not improve. Furthermore, his systolic blood pressure often exceeded 180 mmHg. In traction training with a chin cap, the rubber bands attached to the retractor were too weak to fully elevate his mandible. Thus, we switched to another kind of traction training, with a TMJ brace (brand name Lip Strap). During direct therapy with the Lip Strap, he could keep his mouth closed and swallow a small amount. However, without the Lip Strap, his mouth stayed open and he had trouble swallowing. Continuous traction training allowed him to keep his mouth closed without the Lip Strap on and to ingest a full dosage of pureed food (1,600 kcal/day). He was discharged on the 78th day of hospitalization and returned to the previous hospital.
Discussion: A head MRI revealed abnormalities in the responsible lesion in the masticatory muscles and significant hypotonia of the masticatory muscles, mainly in bilateral masseter. We therefore considered his disturbance to be masticatory paralysis caused by trigeminal paralysis. When wearing the Lip Strap at the initiation of direct therapy, mandibular elevation was supplemented, which allowed him to swallow with his mouth closed. VF revealed that decreased oral cavity volume led to tongue-palate contact. This contact improved delivery of the alimentary bolus to the pharynx and facilitated swallowing. In traction therapy, continuous traction is used for dystonia caused by central nervous system disorder. The Lip Strap’s chin strap maintained a constant fixing force and achieved continuous traction over several hours. These findings suggest that continuous traction with the Lip Strap stimulated masticatory muscle contraction, achieving a closed-mouth state.
Objective: To investigate the association of epileptic seizures with food refusal of infancy or young childhood onset.
Methods: We retrospectively evaluated 4 children with intractable epilepsy who appeared to refuse to eat before the age of 7 years, which necessitated gavage feeding and/or a high density liquid diet.
Results: All had mental retardation with autistic tendencies and intractable frequent epileptic seizures. The appearance or worsening of food refusal were associated with the reduction or control of the epileptic seizures in all of them. On the contrary, a worsening or recurrence of seizures resulted in the improvement or disappearance of food refusal.
Conclusion: The clinical courses with the treatment suggested that the change in seizures per se, rather than a side effect of the antiepileptic drugs, was considered to have an effect on the food refusal. The control of epileptic seizures may induce or worsen food refusal of infancy or young childhood onset.
We report a case of a 69-year-old male patient with severe dysphagia and trismus secondary to tetanus. The patient was treated with anti-tetanus immunoglobulin, penicillin G and metronidazole immediately after he was hospitalized and a tracheotomy was performed to prevent possible aspiration. On the 12th hospital day, a speech therapist (ST) started providing non-swallowing exercises: jaw-opening exercises, stretching the neck muscles, and thermal tactile stimulation to the faucial pillars. The rigidity on the suprahyoid muscles and jaw-opening muscles were remitted by the 31st day; however, dysphagia and mild trismus remained as a risk of aspiration, in which video fluorography showed mid- and post-swallowing aspiration. Additional non-swallowing exercises were provided: the tongue holding maneuver, the Mendelsohn maneuver, and a strengthening exercise for the neck muscles, and a swallowing exercise with jelly also started afterwards. The patient returned to a regular diet on the 49th day and was discharged on the 52nd day with complete improvement of dysphagia and trismus. The appropriate and intensive interventions, including dysphagia rehabilitation by the ST from the early stage of the disease, appeared to have contributed to preventing pulmonary complications in the patient.