Swallowing

Disorders
Protocols for Screening and Patient Management

Introduction
2

Dysphagia
Dysphagia:

The medical term for difficulty

swallowing.

Delay or misdirection of food or liquid

moving from the mouth to the stomach.

Dysphagia can occur at any age, but is

more common in older adults or after a
stroke.

Persons with dysphagia are at high risk

for malnutrition and dehydration.

Causes of Dysphagia
Trauma - accidental, iatrogenic, penetrating trauma,head
injury, or cranial nerve damage

Damage to the muscles or nerves that control swallowing.

Infections - tonsillitis pharyngitis, acute supraglottitis,

tuberculosis

Obstruction in the airway or esophagus can push food into the

trachea during swallowing.

Inflammatory Diseases - GERD, autoimmune disorders like

scleroderma,rheumatoid arthritis

Aspiration Pneumonia
Aspiration Pneumonia is
infection of the lungs and
bronchial tubes after
inhaling oral or gastric
contents, such as food,
liquid, or vomit, and is a
potential outcome of
dysphagia.

Dysphagia and Oral Hygiene

Meticulous control of dental plaque
biofilm reduces number of pathogens in
oral contents.
Oral Bacteria are virulent
S. pneumoniae, H. influenzae, S.
aureus, and Gram-negative strains
(Swaminathan et al, 2016)
Controlling dental plaque reduces risk of
aspiration pneumonia in patients that
aspirate frequently or are
immunocompromised.

Current Status
7

At-Risk Groups
Elderly
People with Developmental Disabilities
Downs syndrome, Autism
People with Traumatic Brain Injuries
People with History of Stroke
Radiation Therapy for Nasopharyngeal Cancer

At-Risk Groups
Elderly
People with Developmental Disabilities
Downs syndrome, Autism
People with Traumatic Brain Injuries
People with History of Stroke
Radiation Therapy for Nasopharyngeal Cancer

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At-Risk Groups
Elderly
Elderly in Nursing Facilities

11

At-Risk Groups
Elderly
Elderly in Nursing Facilities
- Medically compromised
- Polypharmacy
- Undetected Strokes

12

Why Screen for Dysphagia?

Underdiagnosed and Underdetected
- 51% - 78% of stroke patients experience dysphagia within 3
days of stroke onset (Martino et al., 2005)
- 11.4% of healthy people aged 69-98 experience dysphagia

High Mortality
- Developing pneumonia triples your risk of death during the
30 days following a stroke (Srensen et al., 2013).

Poorer Patient Outcomes

- Stroke patients with dysphagia are more likely to need
extended or permanent hospitalization (Altman, 2011).

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Why Screen for Dysphagia?

Routine Dysphagia screening would lower risk of
malnutrition and respiratory complications.
(Serra-Prat et al., 2012)
American stroke association calls for development of
dysphagia screening devices.
All patients should be screened, regardless of
suspicion.

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Why Screen for Dysphagia?

Formal dysphagia protocols reduce risk of
pneumonia and improve patient outcomes
Standardized swallowing screenings and
intensified oral hygiene reduced rate of
pneumonia in stroke victims.
Rate of pneumonia decreased from
27-28% to 7%.
Rate of 30 day mortality decreased
from 22-30% to 12%
(Srensen et al., 2013)

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ADA Position
The ADA states that there is insufficient evidence for
screening guidelines in dysphagia patients.
Large well-designed trials are needed for more
conclusive evidence of screening benefit.
(Martino, Pron, & Diamant, 2000)

Discussion
16

17
Protocols
for
Detection

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Protocols for Detection

Medical History Review - Red Flags
- History of stroke
- History of pneumonia
- Neurologic disorders
- Alzheimer's, Parkinson's,
Dementia
- Tracheotomy
- Rapid, unexplained weight loss

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Protocols for Detection

- Do you have trouble
swallowing?
- Do you avoid any foods?
Why?
- Can you point to where the
problem is located?
(Logemann, Curro, Pauloski, & Gensler, 2013)

Wet vocal quality (wet or gurgling

voice) indicates inability to control
secretions.

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Protocols for Detection

Extraoral Exam
Watery eyes or runny nose
after swallowing.
Rapid breathing, coughing,
or gagging after swallowing
Feeling food gets caught in
throat.
Avoiding certain foods or
textures.

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Protocols for Detection

4 finger Pharyngeal Swallow Procedure
Position the person sitting upright so that the pharynx is vertical.
Position your hand on the person's neck with a light touch.
Index finger under the chin.
Middle finger on the hyoid bone.
Ring finger on the top of the thyroid cartilage.
Smallest finger on the bottom of the thyroid cartilage.
Lack of mobility in larynx suggests incomplete closure of airway during
swallowing and risk of aspiration.
("Bedside Assessment of Swallowing", 2016)

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Protocols for Detection

Intraoral Exam
Drooling
Food residue (pocketing)
Floor of mouth
Roof of mouth
Oral vestibules
Indicates lack of tongue
coordination

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Protocols for
Dental
Management

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Protocols for Patient Management

Patients with dysphagia cannot control their own secretions.

Regular dental hygiene treatment and meticulous removal of denta
biofilm is essential for controlling risk of aspiration pneumonia.
Reduced incidence of aspiration pneumonia by 40%
May prevent one in ten cases of death from pneumonia
(Barnes, 2014)
Improper management during dental treatment can actually induce
aspiration pneumonia.
Patients may aspirate their own oral pathogens during treatment.

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Protocols for Patient Management

Patients with dysphagia cannot control their own secretions
and may aspirate during treatment.
Treat patient upright or semi-supine
If supine, head and body should be raised to 30-45 degrees,
or head tilted to one side.
Maintain oral suctioning throughout treatment.
Oral Hygiene:
Suction toothbrush
For persons who cannot cooperate with toothbrushing, use
12-hourly chlorhexidine gluconate gel or spray
Persons with dysphagia should not use a mouth rinse
(Kelly, Jones, & Davies, 2014)

Conclusion
Dysphagia Teams
The Value of Healthcare Networks

26

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Dysphagia Teams
Typical Members of a Dysphagia Team and Their Roles
Dental Hygienists, RDHAPs, Dentists
Control of dental biofilm and oral pathogens.
Initial detection, especially in underserved populations.
Speech Language Pathologists
Primary case carrier. Assesses and treats oropharyngeal
dysphagia.
(Groher & Crary, 2016)

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Dysphagia Teams
Typical Members of a Dysphagia Team and Their Roles
Ear, Nose, and Throat Doctor
Endoscopy and placement of tracheostomy tube.
Gastroenterologist
Treatment of GERD and esophageal dysphagia.
Dietician and occupational therapist
Provide therapy and strategies to reduce risk of
aspiration, malnutrition, and dehydration
(Groher & Crary, 2016).

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Works Cited
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Bedside Assessment of Swallowing. (2016). D.umn.edu. Retrieved 14 November 2016, from
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of children and adults with dysphagia. Wales: The All Wales Special Interest Group for Special Oral Health Care (SIG).
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Roden, D. & Altman, K. (2013). Causes of Dysphagia Among Different Age Groups. Otolaryngologic Clinics Of North America, 46(6), 965-987.
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Serra-Prat, M., Palomera, M., Gomez, C., Sar-Shalom, D., Saiz, A., & Montoya, J. et al. (2012). Oropharyngeal dysphagia as a risk factor for
malnutrition and lower respiratory tract infection in independently living older persons: a population-based prospective study. Age And Ageing, 41(3),
376-381. http://dx.doi.org/10.1093/ageing/afs006
Srensen, R., Rasmussen, R., Overgaard, K., Lerche, A., Johansen, A., & Lindhardt, T. (2013). Dysphagia Screening and Intensified Oral Hygiene
Reduce Pneumonia After Stroke. Journal Of Neuroscience Nursing, 45(3), E1-E2. http://dx.doi.org/10.1097/jnn.0b013e3182945dd9
Swaminathan, A., Varkey, B., Stearns, D., & Varkey, A. (2016). Aspiration Pneumonitis and Pneumonia: Overview of Aspiration Pneumonia,
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