Purpose: We developed a simple-version oral health care assessment sheet for caregivers, and verified its reliability and validity.
Materials and Methods: The newly developed assessment sheet consists of 10 items to screen for dysphagia selected from the “Seirei Swallowing Questionnaire” and 10 items to evaluate oral hygiene, oral function and the risk for oral health care. We calculated the sensitivity, specificity and Cronbach’s alpha coefficients of the assessment sheet using the original data which were collected when the questionnaire was developed, and examined the criteria for screening of dysphagia. Thirty-four caregivers (mean nursing experience 6.0 years) assessed 143 residents (mean age 86.6) of three nursing homes using the assessment sheet. The evaluation results were analyzed and verified the reliability and validity and examined the criteria for screening of dysphagia.
Results and Discussion: The screening criterion “if responding worst answer A to any item for dysphagia screening, then dysphagia” revealed sensitivity of 86.0% and specificity of 88.9% to the original data. Adding the cut-off value “if more than 4 points for the total screening score (maximum 20 points), then dysphagia” to the criterion enhanced the sensitivity. No significant differences were found in the career of caregivers and disability level of the residents among the three nursing homes. Upon analyzing actual assessment results using the assessment sheet, no significant differences were found in the scores of oral hygiene, oral function and dysphagia items among the three facilities.
The reliability and validity of this assessment sheet as a screening tool for dysphagia were as high as those of the Seirei Swallowing Questionnaire. The consistent assessment results among the three facilities are considered to be the result of listing evaluation criteria such as photos and commentary for non dental professionals.
The prevalence of dysphagia in the three nursing homes was similar to that in other nursing homes in Japan and abroad concerning the criteria “if responding worst answer A to any item for dysphagia screening, then dysphagia” or “if more than 4 points for the total screening score, then dysphagia”. These results suggest the usefulness of the new developed simple-version oral health care assessment sheet.
Purpose: The use of commercial thickeners is prevalent when treating dysphagic persons. Defining thickness levels and the physical characteristics of each level have not been standardized. This study was done to establish three levels of thickness (mildly thick, moderately thick, and very thick) comparing a sensory evaluation to a Line Spread Test (LST) and viscosity measurements.
Methods: Six thickeners (1 starch, 1 guar gum and 4 xanthan gums) were used in this study. Twenty four thickened liquids were made using 4 concentration levels of 6 thickeners. These materials were served to 42 clinicians who have managed dysphagia more than 5 years for a sensory evaluation. They were asked to categorize each sample into one of five numerical categories (1: thinner than “mildly thick”, 2: mildly thick, 3: moderately thick, 4: very thick, and 5: thicker than “very thick”). Averaged evaluation data for each of 24 thickened liquids were calculated. Viscosity was measured using an E-type viscometer at 50 s-1 shear velocity. The same materials were measured with a LST. Correlation of averaged sensory evaluation data with objective viscosity and LST values were analyzed by calculating Pearson's correlation coefficient (r) and a coefficient of determination of regression line (R2). Three categories of thickened liquids by xanthan gum (mildly, moderately and very thick) were chosen to investigate the ranges of viscosity and LST value equivalent to each level of thickness.
Results and Discussion: A strong positive correlation existed between averaged sensory evaluation categories and actual objective viscosity (r＝0.769, R2 ＝0.9183). A strong negative correlation existed between averaged sensory evaluation data and the LST values (r＝－0.942, R2 ＝0.8812). There was a negative correlation between objective viscosity measurements and the LST values (r＝－0.630, R2 ＝0.7264). The objective viscosity measurements and the LST values of level 1 liquids ranged from 55 mPa・s to 100 mPa・s and from 43 mm to 40 mm, respectively. Those of level 2 liquids ranged from 150 mPa・s to 260 mPa・s and from 38 mm to 34 mm, respectively. Those of level 3 liquid ranged from 400 mPa・s to 450 mPa・s and from 32 mm to 30 mm, respectively. Strong correlations between the sensory evaluation, objective viscosity measurements and LST values supports the effectiveness of objective viscosity measurements using E-type viscometer at 50 s-1 shear velocity and LST values in verifying physical characteristics of the thickened liquids.
The Mendelsohn maneuver is one of the popular training methods for swallowing rehabilitation. This method, however, has several problems such as the difficulty of teaching and learning. Therefore, we have been developing a training system for assisting patients to perform laryngeal elevation by using visual biofeedback (BF) of the larynx movement. Its short-term training effects were already verified in our previous studies; in this study we verified its long-term effects using elderly volunteers. The subjects were 10 elderly males (70.3±4.6 y/o, mean±SE). Single laryngeal elevation (LE) was defined as keeping the larynx in higher positions for 5 s. One task comprises three sequential LE steps: 1) LE without BF, 2) LE with BF and 3) LE without BF, with a rest interval of 5–10 min. All subjects performed this task once a day for 5 straight days. Analysis parameters were 1) the amount of laryngeal elevation [mm], 2) duration of laryngeal elevation [s], 3) duration of 5 mm laryngeal elevation [s], and 4) duration of 10 mm laryngeal elevation [s]. Consequently, the amount of laryngeal elevation on the 5th day increased significantly from step 1 to step 2. Regarding the duration of the elevation, a significant increase was observed from step 1 to step 2 on the 1st day in parameters 2), 3) and 4) as well as on the 5th day in parameters 3) and 4). In comparison between the results on the 1st and 5th days, a significant increase was observed in step 2 in parameters 1) and 3). Results regarding the amount of laryngeal elevation demonstrated that all subjects could master elevating the larynx intentionally within 5 days. Results regarding the duration of the elevation demonstrated that a small amount of elevation could also be mastered within 5 days and that visual biofeedback was effective for prolonging the duration of the elevation of 5 mm or more. Elevation of 10 mm or more, however, could not necessarily be mastered, although the biofeedback effectively prolonged its duration. In conclusion, the proposed BF training was verified to be effective for increasing the amount of elevation as well as for sustaining the larynx in higher positions.
In recent years, questionnaires have been used for conducting effective interviews (medical history) for dysphagia. We translated the original English edition of the 10-item Eating Assessment Tool (EAT-10; Belafsky et al., 2008) into Japanese. The original questionnaire consisted of 10 questions and was developed in the United States. The translated questionnaire that was used as a provisional version of the EAT- 10 was examined from the following viewpoints: whether suitable for assessing Japanese subjects and whether appropriate that scoring 3 points in total would be a criterion for suspected dysphagia, similar to that in the original edition. The subjects were 145 patients who were admitted to the convalescent rehabilitation ward (mean age, 67.8±1.2 years). Fifty-eight patients were diagnosed with dysphagia by the medical care team. These subjects completed the provisional EAT-10 version within 2 weeks after hospitalization, and the sensitivity and specificity of the survey results were calculated using each total score. A cutoff value that could be used to diagnose suspected dysphagia was determined. According to the criterion similar to that in the original edition of the EAT-10, 66 subjects who scored total 3 points or more were diagnosed with suspected dysphagia. Considering the numbers of dysphagia patients diagnosed by the medical care team and those diagnosed with suspected dysphagia based on the provisional EAT-10 version score of total 3 points or more, the sensitivity and specificity were assessed as 77.6% and 75.9%, respectively.
Consequently, we consider that the provisional version of the EAT-10 with the cutoff value of 3 points or more, similar to that in the original edition, could be used in Japan.
Meningeal carcinomatosis (MC) is a rare condition with poor prognosis. In this study, we report a case of MC secondary to lung adenocarcinoma presenting with dysphagia. Using a combination therapy of radiation, gefitinib, and dysphagia rehabilitation, the patient eventually achieved full transition from tube feeding to oral feeding. A 72-year-old woman experienced difficulty in swallowing. Dysphagia developed over 3 weeks, resulting in dehydration. On admission, neurological examination revealed dysphagia and diplopia.
Chest computed tomography (CT) and CT-guided cytology revealed lung adenocarcinoma, while brain magnetic resonance imaging indicated MC. Whole-brain radiation was initially performed followed by administration of gefitinib through a percutaneous endoscopic gastrostomy tube. Dysphagia gradually improved, and direct swallowing training was initiated after videofluoroscopic examination of swallowing. Finally, she was able to eat soft food with some assistance. MC should be considered as the differential diagnosis in cases of rapidly deteriorating cranial nerve palsy following dysphagia. Swallowing function recovered in this case, possibly because gefitinib may have been particularly effective.
Detailed evaluation of the patient’s condition should be conducted during the course of treatment for MC, and it is important to appropriately respond, particularly when dysphagia shows an improving trend.
The number of patients with xerostomia has lately been increasing. Saliva contains various enzymes and immunoglobulins, which play important roles in maintaining oral functions. Xerostomia decreases saliva secretion and seriously impairs quality of life, and may also influence oral microbiota. We analyzed the microbiota of the dorsum of the tongue of a severely xerostomic patient using molecular microbiological techniques. We also evaluated the moisture of the oral mucosa and the microbiota of the dorsum of the tongue of the patient after administering a moisturizing spray which contains lactoferrin, β-glucan, and hyaluronic acid. Before administering the spray, bacteria of three genera, Eubacterium, Actinobacterium, and Peptostreptococcus, were detected in the mouth of the patient. These bacteria were thought to be characteristic to the patient since they were not detected in the mouths of healthy controls. Moisture of the oral mucosa increased after 3 weeks’ administration of the moisturizing spray. After 5 weeks’ administration, the microbiota of the patient became closer to that of healthy controls, and the abovementioned bacteria also disappeared. These results in this case with severe xerostomia revealed that administration of the spray effectively improved the moisture of the oral mucosa and changed the oral microbiota pattern.