Category: Dysphagia

he oral cavity is a potential reservoir of pathogens. Not thoroughly brushing the teeth, tongue and palate means making it easier for bacteria to pass into the body.

Oral hygiene care should always be an integral part of one's daily routine, not only for reasons of comfort but especially in terms of safeguarding one's health. In fact, the oral cavity, in addition to being the main route to the digestive and respiratory systems, is also a potential reservoir of pathogens (about 300 species of bacteria) that could cause various ailments. First and foremost, oral diseases, which, in addition to being a serious cosmetic problem, are a cause of dehydration and malnutrition as well as a risk factor for heart disease, diabetes and stroke. Second, poor oral hygiene in dysphagic patients is related to aspiration pneumonias. Failure to brush the teeth, tongue, and palate thoroughly means exposing oneself to an overgrowth of bacteria that, by remaining incubated in the oral cavity, are likely to move within the body. In fact, such pathogens can make entry along with food, drink or saliva and reach the respiratory tract instead of the esophagus. 

Oral hygiene as a daily preventive activity

For the reasons listed, oral hygiene should be one of the fundamental activities for those with dysphagia, especially for those who are unable to provide it independently for both motor and cognitive reasons. However, this is not always the case, and too often oral care is not seen as an integral part of patient care. Similar discussion applies to the evaluative investigation of the oral cavity, which often does not occur with the frequency and tools with which it should instead be carried out.

The greatest risk that can be incurred by administering the meal to a patient with swallowing problems is the passage of food into the airway.

Penetration is defined as the passage of the bolus into the airway above the vocal cords. Normally such penetration is resolved by the protective cough reflex. 

Aspiration is defined as the passage of food debris under the vocal cords. In this case, the cough reflex is not sufficient to expel such residues with serious consequences in the respiratory system.

Aspiration pneumonias are the most common cause of death in patients with dysphagia from neurological disorders. Aspiration is defined as the inhalation of oropharyngeal or gastric contents into the larynx and lower respiratory tract. The risk of aspiration is relatively higher in elderly individuals because of the higher incidence of dysphagia and gastroesophageal reflux. Various pulmonary syndromes can occur after aspiration, depending on both the amount and nature of the aspirated material, the frequency of aspiration, and the host's response to the material.

Aspiration pneumonia proper-or Mendelson syndrome-is a chemical injury caused by the inhalation of sterile gastric contents, while ab ingestis pneumonia is an infectious process caused by the inhalation of oropharyngeal secretions colonized by pathogenic bacteria; although there is some overlap between them, they represent two distinct clinical entities.

Aspiration pneumonia is characterized by chemical burn of the tracheobronchial tree and lung parenchyma due to the acidity of gastric contents, followed by an intense parenchymal inflammatory reaction. Because gastric acidity prevents the growth of microorganisms, microbial infection plays no role in the early stages of aspiration pneumonia, but may have only at a later stage, although the incidence of this complication is poorly known. However, it should be remembered that when the PH of the stomach increases following the use of antacids or proton pump inhibitors,of frequent use in the elderly, colonization of the gastric contents by potentially pathogenic microorganisms may occur.

The signs and symptoms of patients who have aspirated gastric contents range from the presence of gastric regurgitation in the oropharynx to the onset of wheezing, coughing, cyanosis, pulmonary edema, hypotension, and hypoxemia with rapid progression to acute respiratory distress and death. In most cases there is only wheezing or coughing, while some patients present with what is commonly referred to as silent aspiration, which is only evident radiologically.

Pneumonia ab ingestis develops as a result of aspiration from the oropharynx of secretions colonized by microorganisms; however, it should be remembered that this is one of the main mechanisms by which bacteria-such as Haemophilus influenzae and Streptococcus pneumoniae that colonize the oropharynx-penetrate the airways. In fact, about half of healthy adults aspirate small amounts of oropharyngeal secretions during sleep, but their microbial contents are continuously eliminated through active ciliary transport, normal immune mechanisms, and eventual coughing. However, if these mechanisms are compromised or, if the amount of aspirated material is abundant, the onset of pneumonia may occur.

In elderly patients and those who have suffered a stroke and have dysphagia, there is a strong correlation between aspirate volume and the development of pneumonia. 

The diagnosis of pneumonia ab ingestis is based on radiographic evidence of pulmonary infiltrates at the bronchopulmonary level. Factors that increase the risk of oropharyngeal colonization by potentially pathogenic microorganisms and that increase the bacterial load may increase the risk of pneumonia ab ingestis; for example, this risk is lower in patients without teeth and in elderly patients who receive effective and thorough oral cavity care. In fact, inadequate cleaning of the oral cavity may result in abundant oropharyngeal colonization by potential respiratory tract pathogens such as Pseudomonas aeruginosa, Staphylococcus in commonly acquired pneumonia in elderly individuals.

Regarding the causative microbial agents of ab ingestis pneumonia, a predominance of Pseudomonas aeruginosa and other Gram-negative bacteria has been shown in patients with hospital-contracted aspiration syndrome, while Streptococcus pneumoniae and Staphylococcus aureus, Haemophilus influenzae and Enterobacteriaceae are prevalent in community-acquired pneumonia.

It is clear that the passage of food into the respiratory system occurs more frequently during the administration of meals in even early stage dysphagic patients. When such passage is manifested by choking sensation, insistent coughing and the appearance of red or cyanotic coloring, the phenomenon becomes extremely evident to those who are administering the food

 Far more dangerous may be not resolving signs of passage of small amounts of food into the bronchi-silent aspiration-as it may often not be felt by the patient himself. Certain phenomena must induce suspicion including:

• Constant occurrence of a few involuntary coughing fits immediately after, or at least within 2-3 minutes of, swallowing the mouthful
• Occurrence of veiling in the voice or hoarseness after swallowing a mouthful
• Leakage of liquid or food from the nose
• Presence of fever, although not high - 37.5- 38°C - with no obvious cause; fever may in fact be a sign of inflammation or irritation due to food passed into the airways.

If even one of these signs is detected, it is a good idea to report it immediately to the physician and/or, in any case, to the person who is personally involved with the dysphagic disorder.

It is useful to emphasize that the passage of food into the respiratory system, through the trachea into the bronchi and then into the lungs, even in small amounts but with repeated episodes over time, can give rise to a form of pneumonia that begins as inflammation but can evolve, especially if the penetration of food substances into the bronchi persists, into a more serious infectious form. High care, therefore, is required during the feeding of meals both in terms of the manner of feeding-posture, timing, etc.-and the choice of food.

A progression of foods based on the swallowing ability of the patient with swallowing problems should be provided during meal administration. The choice of food, dependent on the type and degree of dysphagia, should be guided mainly by the following criteria:

• Patient safety by limiting the risk of aspiration-passage of food into the airway-through the selection of foods with suitable physical properties (homogeneity, viscosity, cohesion)
• Dietary needs of the patient, with special reference to protein, calorie and water intake, any dietary requirements and dietary preferences.

While it is.necessary for foods to be varied, appetizing, and nutritionally adequate, it is a priority to put in place all actions aimed at preventing the risk of food passing through the airways and the subsequent risk of ab ingestis pneumonia.

Among these actions, we recommend attention to posture, application of correct feeding patterns, and a breakdown of the feeding day into several moments (at least 5) so as to reduce patient strain.

Above all, however, we recommend that the choice of foods be very judicious and that their rheological parameters (especially homogeneity, absence of double phase, consistency, viscosity, viscoelasticity, cohesion) be appropriate for the dysphagic patient, keeping absolutely constant in the various contexts of use, from preparation to the time of administration.

There are many studies by researchers regarding the relationship of people with dementia to food and how they perceive it. They all converge that eating does not solely have a biological function, but represents an incredibly relevant experience. Clearly explaining firsthand the various aspects revolving around food and the action of eating was Wendy Mitchell, who in her book "What I Wish People Knew About Dementia" describes how the disease has changed her relationship with food.

"You can tell me a secret and I will always keep it because I simply won't remember it. But one thing I never forget is that food meant a lot more to me than it does now," is how Mitchell introduces the topic of food in his first-person account of how he experiences dementia.

Different meanings of food

Within any culture, food takes on a very important significance as it becomes the bearer of culinary traditions developed and handed down over time that are closely connected with the territory, its flavors and its community. In other words, food, in addition to being linked to sensory pleasure, plays a very important role on a social level-just think that mealtime is also a way of marking time-and on an affective level. In fact, very often our memories associate flavors, recipes and foods with certain childhood memories and moments of conviviality.

Mitchell describes this aspect like this, "These days I even have to set alarm clocks on my iPad to remind me to eat-the hunger-sensing part of my brain stopped working a long time ago. Yet, when you no longer feel pleasure from food, you realize it is so much more. It's the way we show love as parents, it's the way we bond with friends, it's an excuse for saying the wrong thing, it's a welcome to the neighborhood."

He adds, "Even when I was diagnosed with young-onset Alzheimer's in 2014 at the age of 58, I used food in a way to sweeten the bitter moments that followed."

Dementia changes not only eating habits but also cooking habits

When you have dementia, not only your eating habits change, but also your cooking habits because cooking becomes a big problem. As the disease progresses, it is increasingly difficult to remember even the simplest things, such as making a cup of tea. Mitchell also chronicles this aspect by showing how cooking goes from being an act of love for self and others to a time of frustration, anger and helplessness and those places of colors, scents and creativity become mazes, confusion and chaos. Losing the ability to cook can be experienced as real grief.

In this case, only the love of our loved ones can really help us regain a positive sense of food preparation. Mitchell recounts, "My son-in-law, Stuart, now cooks for me, only two or three times a week, so I don't feel intrusive. But his are the only freshly prepared meals." There remains the gesture of love that is now received instead of given, but still represents a positively perceived moment of relationship. Thus, the moment of the meal can continue to bring pleasure on the relational level, despite the fact that the perceptual and sensory one is diminished.

Eating out can also become very difficult. Mitchell herself acknowledges this: "Eating out used to be a luxury, but now it's very stressful," and then adds, "In restaurants, I choose the first thing I recognize that will be easy to eat. Never meat, because it requires the right coordination to cut into small manageable pieces, and that left me a long time ago. The simple task of cutting food requires serious concentration. Even chewing is not as easy as it used to be."

Understanding what the real capabilities of people with dementia are also becomes essential in proposing food and contexts in which to consume it. It is important to come to terms with the new rhythms and habits of the person with dementia, who cannot control his or her behavior and memory.

How to make people with dementia experience food better

What can be done to make people with dementia experience food as best as possible is to consider as many aspects as possible and be attentive to each other without underestimating anything, in the hope that even mealtimes will be experienced as pleasant and worthwhile at all times. This can often translate into making the act of eating or drinking easier to allow to the extent possible a certain amount of autonomy. Thus, choosing meals that they are able to consume on their own or presenting the dish in such a way that they can consume it independently.

"We don't know for sure what causes dementia and we don't know what to eat or drink to prevent it. All I know is that every day is a challenge, a chess game to play with this disease in my head and one that I am determined to win for as long as possible." Wendy Mitchell.

Unlike dysphagia, atypical swallowing is a disorder due to a failure of the swallowing act to evolve from the primary infant stage.

Exactly like dysphagia, atypical swallowing is among the so-called swallowing disorders. It is generated due to a failure of the swallowing act to evolve from the primary infantile stage, which may occur in children over seven years old or in adults. Atypical swallowing is thus due to the persistence of an infantile swallowing pattern.

The change in swallowing type corresponds to the developmental stage of the baby in which the front teeth appear, the change de food from liquid to solid, the change in postural patterns that initiate autonomous walking and the development of the temporomandibular joint .

Alterations in these transitions or repeated vices to excess (bottle, pacifier, etc.) may result in the delay or non-onset of the adult physiological swallowing reflex, with permanence of the infant swallowing reflex

Common causes of atypical swallowing in children and adults, on the other hand, are all nasal cavity conditions such as recurrent or chronic rhinitis, sinusitis, and adenoid hypertrophy that result in mouth breathing, preventing proper tooth closure and low tongue when swallowing.

Clearly, this is a very different disorder from dysphagia, which is a secondary symptom of much more serious conditions. Atypical swallowing, on the other hand, is a dysfunction of one or more stages of the mechanics of swallowing that also causes improper transit of food through the upper digestive tract.

How does infant swallowing occur?

Given the daily intake of liquid food through breast or bottle feeding, the infant tends to protrude his tongue between the gums and clench his lips in order to produce enough pressure to allow him to swallow. This swallowing pattern tends, with development, to change depending on feeding and the different way of feeding.

After a so-called infantile swallowing phase, the child gradually changes the type of swallowing act as a result of the appearance of anterior deciduous teeth and the change in feeding patterns (from a totally liquid diet to a diet composed a also of money foods). Between 18 and 28 months, the child's swallowing is called mixed swallowing.

In later months, as the child takes in solid foods, he or she will begin to tighten the mouth after chewing to allow the tongue to push the food against the palate and thus toward the throat and then direct it to the digestive tract.

Types of atypical swallowing

Having analyzed the swallowing mechanism in infancy it is now easier to describe the different types of atypical swallowing. The main ones include the following:

- Simple lingual thrust swallowing: this is a disorder that is not particularly severe and is easily reeducated because the subject, when swallowing, clenches the teeth normally and does not place the tongue between the dental arches. In these cases, the following frequently occur: circumscribed open bite, lingual profusion on the alveolar arches during swallowing, contraction of the elevator muscles, tendency to a posture with a low tongue and risk of oral respiration, predominantly vertical chewing, and tendency to assume an ogival shape of the palate.

- Complex lingual thrust swallowing: significantly more severe than the previous one, it causes various disorders. These include: anterior bite reaching up to the premolars, significant lingual profusion between the dental arches, failure to lock the teeth during swallowing, anterior chewing, and frequent dental malocclusions.

• True infant swallowing: this is the form of atypical dysphagia most similar to the infant's swallowing pattern. In these cases, the following occur: permanence of the infant swallowing reflex, strong lingual thrust between the dental arches, failure to clench the teeth during swallowing, decreased facial expressions, and frequent oral breathing even at times of rest.

Consequences of atypical swallowing

Failure to treat atypical swallowing therapeutically can result in more than just dental disorders. These include:

• protruding teeth (tooth overjet);
• ogival palate;
• Chewing alterations;
• postural problems;
• Phonation disorders;
• Aesthetic alterations;
• Aerophagia and hysterical globe.

Dysphagia is a common disorder related to swallowing difficulty that can occur at all ages, although it is prevalent among the elderly population. This problem can be temporary or permanent and can affect both men and women. But what is it specifically about?

What is dysphagia?

The term dysphagia denotes any disturbance in the progression of food from the mouth to the stomach and can involve any of the stages of swallowing. Swallowing is the ability to channel solid, liquid, gaseous, or mixed substances (food or drink, alone or together) from the mouth to the stomach.

It is a complex process involving rapid coordination of a set of muscles that allows on the one hand the passage of the bolus-that is, the chewed, kneaded, saliva-soaked food-to the digestive system and on the other hand the protection of the airway and lungs from the danger of aspiration and/or penetration.

Swallowing is a process that is partly voluntary and partly reflexive in nature, as some stages are not under our control and are therefore involuntary. If there are complications during this process, there can be even serious consequences, such as ab ingestis pneumonia.

Recognizing this disorder in time is critical to patient safety and life.

What are the causes of dysphagia?

Dysphagia can have several causes, and according to the American Gastroenterological Society they can be classified as follows:

• Neurological - trunk tumors, head trauma, stroke, cerebral palsy, Guillain-Barré syndrome, Huntington's disease, poliomyelitis, post-polio syndrome, tardive dyskinesia, metabolic encephalopathies, multiple sclerosis, amyotrophic lateral sclerosis, dementia, Parkinson's disease, and Alzheimer's disease;
• Structural- cricopharyngeal bar, Zenker's diverticulum, cervical scars, oropharyngeal tumors, congenital malformations, osteophytes, and skeletal malformations;
• Myopathic-connective diseases (overlap syndrome), dermatomyositis, myasthenia gravis, sarcoidosis, myotonic dystrophy, oculopharyngeal dystrophy, polymyositis, paraneoplastic syndromes;
• Iatrogenic - side effects of drug therapies, post-surgery consequences of muscle or neurogenic surgery, effects from radiation exposure, corrosive (pill injury, intentional);
• Infectious-diphtheria, botulism, Lyme disease, syphilis, mucositis (from herpes, cytomegalovirus, candida, etc.);
• Metabolic-amyloidosis, Cushing's syndrome, thyrotoxicosis, Wilson's disease.

If dysphagia is suspected, it is desirable to contact your physician and follow the necessary process for diagnosing the disorder to understand its degree of severity and how to respond.