Dentistry considerations for the dysphagic patient: Recognition of condition and management
Regular dental visits are important to maintain oral health. However, dental procedures can pose an aspiration risk if dentists are unaware about the patient's dysphagia. Treatment positions, such as lying patients supine, and the use of fluids during dental procedures may contribute to aspiration. Dysphagic patients may be unable to control and manage oral fluids safely due to reduced buccal, lingual and palatal muscle tone and strength. This may cause spillage of fluids into the pharynx. Patients also may have reduced pharyngeal strength and poor airway protection. They could inadvertently ingest and aspirate on fluids, debris and bacteria during dental procedures. In addition, some dysphagic patients may silently aspirate due to poor sensory feedback. This means they may not report difficulties or show overt symptoms such as coughing, choking, gagging or gurgling.
The prognosis of the patient's dysphagia is helpful for dentists to make clinical decisions around the importance and urgency in carrying out dental procedures. Dentists may withhold certain procedures if the patient's dysphagia is likely to resolve over six months. Preventive measures should commence early if the dysphagia is likely to deteriorate over time.
The Speech Therapy Department in Singapore General Hospital, in collaboration with National Dental Centre Singapore, developed a card for individuals with dysphagia to alert their dental professionals about their dysphagia prior to any procedures being carried out.
During registration, dentists usually obtain patients' medical histories and medication usage via the use of self-reported questionnaires. These questionnaires should also include the presence and severity of dysphagia. Dentists should also confirm with patients on the presence of dysphagia prior to each session, as dysphagia severity could change with time. Dentists should be able to recognize general symptoms of dysphagia (Table 2)11 together with potential signs of difficulty managing fluids during dental procedures. The severity of dysphagia must be considered when formulating dental treatment plans. Dentists should understand the patient's need for fluid modifications, such as limiting the bolus size or changing the thickness of their beverages. This helps dentists gauge the risk of using fluids during procedures; for example, a patient who can manage only teaspoon amounts may not tolerate the use of water spray. Manual dental caries removal and scaling of teeth with hand instruments is encouraged. Patients who are unable to drink safely via continuous drinking will suggest their inability to control the continuous flow of fluids in larger amounts. Those who require thicker fluid consistencies for drinking are at higher risk of aspiration. Some dysphagic patients also have decreased neurosensory perception which impedes the protective coughing reflex. Adequate suction and saliva evacuation with help from dental surgery assistants prevent fluid accumulation during treatment. The dental team must keep their focus during procedures to reduce aspiration risk and not rush through treatment
A supine position during dental treatment should be avoided as it results in fluids flowing towards the oropharynx and increases aspiration risk. The treatment chair should not tilt more than 45 degrees (Figure 3). If aspiration risks are not managed, the patient can aspirate during treatment and may develop life-threatening severe aspiration pneumonia. After dental procedures, patients should be advised to monitor for signs of aspiration pneumonia, such as shortness of breath, cough or fever, and to seek immediate medical attention if unwell.
Protection of the airway during dental procedures is important when treating dysphagic patients. The use of a gauze trap or rubber dam prevents filling residues and small dental objects like crowns or implant screws from dropping into the oropharynx. Small dental tools such as implant screwdrivers can be secured with dental floss attached out of the mouth for easy and immediate retrieval if there is a loss of grip. Foreign body ingestion or aspiration could occur if a dislodged object is not retrieved before it passes the oropharynx. It can be fatal if the foreign body enters the airway and results in laryngeal spasm or airway obstruction.
When using impression materials, dentists should select the right sized impression tray for dental arch impression. Impression material of optimum viscosity should be used. The use of runny impression mix or excessive amounts of impression should be avoided as it can result in choking and aspiration. The patient should sit upright for the procedure. The use of high vacuum suction will aid in the removal of impression residue.