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Swallowing dysfunction and aspiration
Oral/Systemic Swallowing dysfunction and aspiration Background.—Japan and most other countries throughout the world are experiencing a growth in the number of elderly persons in their populations. Part of this growth is an increase in the number of elderly who require long-term care (LTC) because of dementia or frailty. Swallowing disorders are a common problem in elderly persons in LTC and is associated with aspiration pneumonia and loss of pleasure in eating. The subtle physiological changes in swallowing function that occur with aging affect both the oral and the pharyngeal phases of swallowing. Combining this difficulty with conditions such as strokes and dementia can predict the presence and severity of a swallowing problem. Silent aspiration (SA) is another problem defined as aspiration without clinical signs such as coughing or clearing the throat. The detection of aspiration or SA is ideally done through use of the videofluoroscopic swallowing examination (VFSE) or fiberoptic endoscopic examination of swallowing (FEES), but these tests are impractical for use on all patients suspected to have swallowing dysfunction. Simple screening methods can also be used, such as the modified water swallowing test (MWST) or the cough test. In addition, nurses and other care providers can only detect swallowing dysfunction early if they understand the factors that accompany the problem. A study was undertaken to identify the prevalence of aspiration and SA in elderly patients in LTC using simple screening tests and to investigate relationships between aspiration, SA, oral ability, dementia severity, vital functions, and nutritional status.
Table 3.—Predicting suspected aspiration and silent aspiration Factor
ORy
95% CI
P value
Age Sex Lip closure Lingual movement Rinsing ability Age Sex Dementia severity (CDR)
1 1$3 5$6 4$2 2$8 1 0$3 2$2
0$9–1$0 0$6–2$7 2$3–13$8 1$7–10$1 1$3–6$1 0$9–1$0 0$1–1$1 1$2–4$1
0$804 0$486 <0$001 0$001 0$012 0$292 0$066 0$01
Upper section: Univariate and multivariate analyses with suspected aspiration as the dependent variable and each of the additional factors as independent variables. Lower section: Univariate and multivariate analyses with silent aspiration as the dependent variable and each of the additional factors as independent variables. y Odds ratio, adjusted by age and sex. (Courtesy of Sakai K, Hirano H, Watanabe Y, et al: An examination of factors related to aspiration and silent aspiration in older adults requiring long-term care in rural Japan. J Oral Rehabil 43:103-110, 2016.)
278
Dental Abstracts
Methods.—The 393 people in LTC included 89 men and 304 women age 65 to 100 years. All underwent the MWST, cervical auscultation, and the cough test to determine their swallowing function status. Patients suspected to have aspiration and/or SA were assessed for oral ability (lip and tongue function plus rinsing and gargling ability); dementia severity; vital functions; and nutritional status. Results.—Severe dementia was found in a substantial percentage of the participants. Most obtained their nutrition orally and most lived in nursing homes. Patients with suspected aspiration had reduced oral ability and nutritional status, more severe dementia, and more severe compromises in performing activities of daily living (ADL) as measured by the Barthel Index (BI), which delivers a score from 100 (complete self-sufficiency) to 0 (complete dependency). SA was diagnosed in 50.9% of the participants, with 23.4% having no cough. Elderly patients with SA without cough had more severe dementia and ADL disability along with reduced nutritional status compared to those with cough. Oral ability was similar between the two groups. Logistic regression indicated that the most significant predictors of aspiration were lip closure, lingual movement, and rinsing ability (Table 3). The most significant predictor of suspected SA was dementia severity. Discussion.—The literature has documented associations between aspiration and dysphagia, ADL, and nutrition status, but in the current study, oral ability and dementia severity demonstrated stronger associations with aspiration than these other factors. Performing the simple screening tests was sufficient to indicate suspected swallowing disorders in the sample population. Causal relationships could not be evaluated.
Clinical Significance.—Practitioners in even remote areas can perform the simple water test to indicate if a patient has swallowing dysfunction. If the patient also has factors related to swallowing impairment, suspected aspiration and SA can be further characterized and interventions planned.
Sakai K, Hirano H, Watanabe Y, et al: An examination of factors related to aspiration and silent aspiration in older adults requiring long-term care in rural Japan. J Oral Rehabil 43:103110, 2016
Reprints available from H Hirano, Research Team for Promoting Independence of the Elderly, Tokyo Metropolitan Inst of Gerontology, 35-2 Sakae-cho, Itabashi-ku, Tokyo 173-0015, Japan; e-mail: [email protected]
Orthodontics Treatment duration Background.—Comprehensive orthodontic treatment takes a long time—but how long is needed is unclear. As orthodontic treatment is offered to adults and as modern adjuncts are being added, treatment times may be reduced. If treatment takes an excessive amount of time, patients are more susceptible to iatrogenic consequences related to appliance therapy, which includes root resorption and plaque-induced conditions. Patient compliance and quality of life also suffer, especially for adult patients. Shorter treatment times may offer some advantages to both the treatment provider and the patient, but can also have disadvantages. Both patients and practitioners need to appreciate the expected length of orthodontic treatment before they engage in it. The duration of orthodontic treatment using fixed appliances was investigated. Methods.—The data came from a search of the electronic databases MEDLINE via OVID, Cochrane Oral Health Group’s Trials Register, and the Cochrane Central Register of Controlled Trials (CENTRAL). Unpublished literature searches included ClinicalTrials.gov and the National Research Register. Twenty-five articles were selected according to the search criteria, and, after quality assessment, 22 qualified for use in a meta-analysis. Twenty studies were randomized controlled trials and 5 were controlled clinical trials. Results.—Mean treatment duration based on 22 studies of 1089 participants was 19.9 months, with a range from 14 to 33 months. The average duration of treatment based on 1211 participants included in 25 studies was 20.02 months. Mean number of visits required was 17.81. Discussion.—The studies indicate that the average length of a comprehensive course of orthodontic treatment
should be about 20 months, although a wide range of treatment lengths were reported. The most significant determinant of treatment duration is the treating clinician, especially his or her treatment planning decisions, standards, and finishing practices. Other factors include the severity of the malocclusion, extraction-based therapy, multidisciplinary treatment involving hypodontia or orthognathic surgery, and the alignment of impacted teeth. In addition, it’s important to mention clinician experience and patient compliance as other influential factors that can extend treatment duration.
Clinical Significance.—Patients appreciate being told how long a course of treatment will last before they commit to the plan. Telling them that their orthodontic treatment will take about 2 years seems to be a reasonable statement, based on this study. However, they should also be told that treatment duration isn’t set in stone and various factors will extend the time needed to obtain the desired result.
Tsichlaki A, Chin SY, Pandis N, et al: How long does treatment with fixed orthodontic appliances last? A systematic review. Am J Orthod Dentofacial Orthop 149:308-318, 2016 Reprints available from PS Fleming, Dept of Orthodontics, Barts and the London School of Medicine and Dentistry, Inst of Dentistry, Queen Mary Univ of London, Turner St, London E1 2AD United Kingdom; e-mail: [email protected]
Volume 61
Issue 5
2016
279
Table 3.—Predicting suspected aspiration and silent aspiration Factor
ORy
95% CI
P value
Age Sex Lip closure Lingual movement Rinsing ability Age Sex Dementia severity (CDR)
1 1$3 5$6 4$2 2$8 1 0$3 2$2
0$9–1$0 0$6–2$7 2$3–13$8 1$7–10$1 1$3–6$1 0$9–1$0 0$1–1$1 1$2–4$1
0$804 0$486 <0$001 0$001 0$012 0$292 0$066 0$01
Upper section: Univariate and multivariate analyses with suspected aspiration as the dependent variable and each of the additional factors as independent variables. Lower section: Univariate and multivariate analyses with silent aspiration as the dependent variable and each of the additional factors as independent variables. y Odds ratio, adjusted by age and sex. (Courtesy of Sakai K, Hirano H, Watanabe Y, et al: An examination of factors related to aspiration and silent aspiration in older adults requiring long-term care in rural Japan. J Oral Rehabil 43:103-110, 2016.)
278
Dental Abstracts
Methods.—The 393 people in LTC included 89 men and 304 women age 65 to 100 years. All underwent the MWST, cervical auscultation, and the cough test to determine their swallowing function status. Patients suspected to have aspiration and/or SA were assessed for oral ability (lip and tongue function plus rinsing and gargling ability); dementia severity; vital functions; and nutritional status. Results.—Severe dementia was found in a substantial percentage of the participants. Most obtained their nutrition orally and most lived in nursing homes. Patients with suspected aspiration had reduced oral ability and nutritional status, more severe dementia, and more severe compromises in performing activities of daily living (ADL) as measured by the Barthel Index (BI), which delivers a score from 100 (complete self-sufficiency) to 0 (complete dependency). SA was diagnosed in 50.9% of the participants, with 23.4% having no cough. Elderly patients with SA without cough had more severe dementia and ADL disability along with reduced nutritional status compared to those with cough. Oral ability was similar between the two groups. Logistic regression indicated that the most significant predictors of aspiration were lip closure, lingual movement, and rinsing ability (Table 3). The most significant predictor of suspected SA was dementia severity. Discussion.—The literature has documented associations between aspiration and dysphagia, ADL, and nutrition status, but in the current study, oral ability and dementia severity demonstrated stronger associations with aspiration than these other factors. Performing the simple screening tests was sufficient to indicate suspected swallowing disorders in the sample population. Causal relationships could not be evaluated.
Clinical Significance.—Practitioners in even remote areas can perform the simple water test to indicate if a patient has swallowing dysfunction. If the patient also has factors related to swallowing impairment, suspected aspiration and SA can be further characterized and interventions planned.
Sakai K, Hirano H, Watanabe Y, et al: An examination of factors related to aspiration and silent aspiration in older adults requiring long-term care in rural Japan. J Oral Rehabil 43:103110, 2016
Reprints available from H Hirano, Research Team for Promoting Independence of the Elderly, Tokyo Metropolitan Inst of Gerontology, 35-2 Sakae-cho, Itabashi-ku, Tokyo 173-0015, Japan; e-mail: [email protected]
Orthodontics Treatment duration Background.—Comprehensive orthodontic treatment takes a long time—but how long is needed is unclear. As orthodontic treatment is offered to adults and as modern adjuncts are being added, treatment times may be reduced. If treatment takes an excessive amount of time, patients are more susceptible to iatrogenic consequences related to appliance therapy, which includes root resorption and plaque-induced conditions. Patient compliance and quality of life also suffer, especially for adult patients. Shorter treatment times may offer some advantages to both the treatment provider and the patient, but can also have disadvantages. Both patients and practitioners need to appreciate the expected length of orthodontic treatment before they engage in it. The duration of orthodontic treatment using fixed appliances was investigated. Methods.—The data came from a search of the electronic databases MEDLINE via OVID, Cochrane Oral Health Group’s Trials Register, and the Cochrane Central Register of Controlled Trials (CENTRAL). Unpublished literature searches included ClinicalTrials.gov and the National Research Register. Twenty-five articles were selected according to the search criteria, and, after quality assessment, 22 qualified for use in a meta-analysis. Twenty studies were randomized controlled trials and 5 were controlled clinical trials. Results.—Mean treatment duration based on 22 studies of 1089 participants was 19.9 months, with a range from 14 to 33 months. The average duration of treatment based on 1211 participants included in 25 studies was 20.02 months. Mean number of visits required was 17.81. Discussion.—The studies indicate that the average length of a comprehensive course of orthodontic treatment
should be about 20 months, although a wide range of treatment lengths were reported. The most significant determinant of treatment duration is the treating clinician, especially his or her treatment planning decisions, standards, and finishing practices. Other factors include the severity of the malocclusion, extraction-based therapy, multidisciplinary treatment involving hypodontia or orthognathic surgery, and the alignment of impacted teeth. In addition, it’s important to mention clinician experience and patient compliance as other influential factors that can extend treatment duration.
Clinical Significance.—Patients appreciate being told how long a course of treatment will last before they commit to the plan. Telling them that their orthodontic treatment will take about 2 years seems to be a reasonable statement, based on this study. However, they should also be told that treatment duration isn’t set in stone and various factors will extend the time needed to obtain the desired result.
Tsichlaki A, Chin SY, Pandis N, et al: How long does treatment with fixed orthodontic appliances last? A systematic review. Am J Orthod Dentofacial Orthop 149:308-318, 2016 Reprints available from PS Fleming, Dept of Orthodontics, Barts and the London School of Medicine and Dentistry, Inst of Dentistry, Queen Mary Univ of London, Turner St, London E1 2AD United Kingdom; e-mail: [email protected]
Volume 61
Issue 5
2016
279