We’ve all been there before: you’re sitting at the dentist’s and can sense the burning question about to be asked, “So, how often do you floss?”. You’ve likely joked or even lied about your flossing habits at one point in your life. I admit I’m one of those people, but after speaking with Richelle Chuka, a Registered Dental Hygienist, I’ve thought twice about skipping flossing in my oral care routine. Richelle shares the importance of maintaining your oral health not just for the sake of good breath and clean teeth – but for your overall health. In this article, we chat with Richelle about oral health and the challenges or oral health for those living with dysphagia.
What is Oral Health?
The Center for Disease Control and Prevention refers to oral health as “the health of teeth, gums, and the entire oral-facial system that allows us to smile, speak and chew” . Although largely preventable, oral diseases, such as tooth decay, cavities, gum disease, and oral cancers, affect nearly 3.5 billion people worldwide . Despite the efforts of dental professionals to educate and prevent oral diseases, oral health is often overlooked as a key factor in our overall health.
Oral Health and Dysphagia
Oral health is especially critical for individuals with dysphagia due to the additional risk factors associated with swallowing disorders. Adam, a head and neck cancer survivor and patient of Richelle, noted, “Prior to having surgery [to remove part of my tongue], I never gave any thought to swallowing, talking, saliva, or the role of my tongue in swallowing and speaking.” He also didn’t realize how much surgery and radiation treatment would impact his mouth, swallowing, and saliva until afterwards. As with many patients post-surgery and radiation treatment, it was a steep learning curve for Adam to manage his newly diagnosed dysphagia, oral health, and figure out what worked best for him. “They must have talked about it beforehand, but I was so overwhelmed I don’t think I was taking in any information at that time.” With the help of his dental team, Adam recognized that taking care of his oral health needed to be a priority.
Oral Health: The gateway to your health
Our mouths are a gateway for bacteria, some good and some harmful that cause diseases. They can enter and spread to other parts of the body such as through the bloodstream . Diseases such as stroke, diabetes, and pneumonia can worsen because of the increased bacteria in the mouth due to the various reasons mentioned below.
- Our tongue is a strong muscle that helps with swallowing, clearing the mouth of food and more. The tongue becomes weak after a stroke or when part of it is removed due to cancer. After surgery, Adam’s weaker tongue made it difficult for him to move food when swallowing and clear his mouth of food. When food is not cleared either by the tongue, flossing, or brushing – it creates an ideal environment for bacteria to multiply. Food or liquid that isn’t removed can also enter the lungs and cause an infection. This is called aspiration pneumonia. If left untreated, aspiration pneumonia can lead to serious complications or even death .
- Saliva production can also be impacted if the salivary glands are removed or damaged during cancer surgery. The tongue and saliva act as a self-cleaning duo to clear accumulating plaque and food. When tissues of the mouth, and teeth cannot be cleansed by saliva, it can lead to increased bacterial growth. Again, the more bacteria growth, the greater the risk of aspiration pneumonia and infections in the mouth that cause oral disease.
- Diet may play a role in your oral health. For example, eating crunchy foods such as raw vegetables and nuts is another way to clean our teeth. “Saliva is a natural protector against harmful bacteria that cause cavities. These foods increase saliva production, which then helps clean your teeth in addition to manually cleaning your teeth by brushing and flossing,” explains Richelle.
The trouble is that when you have dysphagia and are prescribed a texture-modified diet, avoiding certain food textures, such as crunchy foods, may be recommended. Without these crunchy texture foods in your diet to help clean your teeth, you will need to incorporate extra oral cleaning into your routines. Without the extra routines of oral care, bacteria can accumulate putting you at risk for aspiration pneumonia again.
- Other factors that may have an impact. Physical and cognitive abilities required for performing oral health routines such as brushing and flossing may be impacted following a stroke, cancer treatments or a diagnosis of neurological disorders such as dementia. In addition, studies have found negative impacts on oral health when individuals depended on someone else to perform their oral care routines. These individuals were found to be eight to ten times more likely to get aspiration pneumonia .
“You can see how one thing leads to another,” Richelle points out. Unfortunately, individuals with dysphagia may experience one or more of these difficulties, which can make it difficult to keep up with maintaining good oral health . Fortunately, there are many tips, tricks, resources, and support to share as you figure out your new oral health care routine.
Tips and Tricks for Maintaining Your Oral Health while Managing Dysphagia
Here are some tips and tricks from Richelle and Adam:
- Remove food residue after every snack and meal. This means clearing the mouth, cheeks, under the tongue and teeth of food residue either with your tongue or manually by flossing and brushing. Oftentimes, more pockets of food are found when individuals have dysphagia because of the weakened tongue .
- Clean your entire mouth. “Simply put, nothing beats daily brushing, flossing, and rinsing after every meal and snack,” explains Richelle. This includes cleaning the gums, tongue, palate (roof of the mouth) and dentures – not just the teeth.
- Choose a soft-bristle toothbrush. People tend to think toothbrushes with hard bristles clean better. However, soft bristle toothbrushes are gentle on the teeth and gums while still being effective in removing bacteria and plaque.
- Consider the size and shape of your toothbrush. Not all toothbrushes are one-size-fits-all. Instead, find a toothbrush that allows you to reach all the way to your back teeth. These areas of your mouth are often missed when larger toothbrushes are used, leaving uncleaned areas in the mouth and a place for bacteria to multiply.
- Keep your lips moisturized and mouth moist. The lack of saliva due to some medical procedures and medications can dry out the mouth and cause dry and cracked lips. Lip balm can prevent infections from entering any painful cracked lip openings. In addition, water throughout the day or mouthwash designed for dry mouth helps to keep the mouth moist to relieve discomfort and reduce your risk of cavities, gingivitis, and mouth infections. Remember to check with your Speech-Language Pathologist if this is safe for you.
- Don’t overdo it with mouthwash. That burning feeling you get when using mouthwash may feel like it’s doing its job. But, in reality, it may be getting rid of the good bacteria that help fight harmful bacteria. Richelle suggests using mouthwash without alcohol or simple salt water rinse to prevent drying out the mouth and maintain the good bacteria.
- Visit your dentist and dental hygienist regularly. Prevention is key. Your dental team can check your mouth for potential problems before they even start. Adam agrees, “Absolutely number one advice is to establish a relationship with a dental hygienist and dentist.” Your dental team will be a source of support when there are barriers to achieving oral health. For example, sitting upright during an appointment due to difficulties controlling their swallowing while lying.
- Avoid using liquids for oral care if advised by your Speech-Language Pathologist. Given dysphagia’s nature and safety concerns, adaptations will need to be made to your oral care routine. Some of these include:
- Reducing the amount of water to rinse to lower your risk of swallowing liquids;
- Using non-foaming toothpaste to prevent or decrease the risk of swallowing liquids; and
- Positioning yourself in an upright position or on your side while performing your oral care routine.
“I really want to keep my teeth as long as possible. I just don’t believe implants nor dentures can beat my original teeth.” -Adam
For many, the importance of oral health is often not realized until it’s too late. Oral infections such as gum disease, cavities, and tooth infections are usually painless early on and can develop serious oral diseases [8, 9]. The good news is that most oral diseases is preventable with healthy oral care routines and support from your dental team. Remember, you’re not alone in this. There are many resources and supports available for you to access such as the ones at the end of this article.
“There’s no magic pill for better oral health. Even if there was a one, I wouldn’t be able to swallow it anyways.” -Adam
Adam shares his final pieces of advice: “It can feel lonely and isolating so involve your caregiver and join support groups. Relying solely on your dental team doesn’t work either– you need to put the work in too since you will be the one who has to live with the consequences. Educate yourself by asking a million questions and experiment to find out what products work best for you. Be relentless.”
Have a story about your path to better oral health or additional tips? Let us know by sending us a message at: firstname.lastname@example.org
Disclaimer: The information here is meant to support people with dysphagia and their friends and families. It is not, in any way, meant to replace treatment or consultation with medical professionals. For more information about your individual needs, speak to the medical professionals on your care team.
Supports and Resources
- Alberta Dental Association: Oral Health Basics
- Canadian Dental Association: Your Oral Health
- Dental Hygiene Canada: Your Oral Health
- Government of Canada: Oral health tips for caregivers supporting older adults living with dementia at home
- Get Your Spit Together!: Your saliva may hold the secret to better dental checkups
- Young Tongues Global – @youngtonguesglobal: “Peer to Peer support group made up of young people in their 20s, 30s, 40s and 50s who have been diagnosed with Tongue Cancer.”
- Support for People with Oral, Head, and Neck Cancer – @spohncusa: “Dedicated to raising awareness & meeting the needs of oral and head and neck cancer patients through its resources and publications.”
- Head and Neck Cancer Alliance – @hncalliance: “We save lives through prevention, early detection, and research of head and neck cancer.”
- Centers for Disease Control and Prevention. (2022, April 2). Oral health conditions. Retrieved July 23, 2022, from https://www.cdc.gov/oralhealth/conditions/index.html
- World Health Organization. (2022, March 15). Oral health. Retrieved July 14, 2022, from https://www.who.int/news-room/fact-sheets/detail/oral-health
- Mayo Clinic. (2021, October 28). Oral Health: A window to your overall health. Retrieved September 23, 2022, from https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/dental/art-20047475
- Rozas, N. S., Sadowsky, J. M., Stanek, J. A., & Jeter, C. B. (2020). Oral health assessment by lay personnel for older adults. JoVE (Journal of Visualized Experiments), (156), e60553. DOI: 10.3791/60553
- Langmore, S. E., Terpenning, M. S., Schork, A., Chen, Y., Murray, J. T., Lopatin, D., & Loesche, W. J. (1998). Predictors of aspiration pneumonia: how important is dysphagia?. Dysphagia, 13(2), 69-81. DOI: 10.1007/PL00009559
- Bramanti, E., Arcuri, C., Cecchetti, F., Cervino, G., Nucera, R., & Cicciù, M. (2012). Dental management in dysphagia syndrome patients with previously acquired brain damages. Dental Research Journal, 9(4), 361. PMCID: PMC3491320
- Weimers, M. J., & Pillay, M. (2021). Pathogenic oral bacteria in hospitalised patients with dysphagia: The silent epidemic. South African Journal of Communication Disorders, 68(1), 1-7. DOI: 10.4102/sajcd.v68i1.798
- Gaurilcikaite, E., Renton, T., & Grant, A. D. (2017). The paradox of painless periodontal disease. Oral Diseases, 23(4), 451-463. DOI: 10.1111/odi.12537