Effect of poor oral health status at hospital admission on in-hospital outcomes of older patients with aspiration pneumonia

PURPOSE

To investigate the effects of oral health status at admission on in-hospital outcomes and how it varies during hospitalization in older patients with aspiration pneumonia.

METHODS

This prospective cohort study involved patients aged ≥ 65 years who were admitted to an acute care hospital with a diagnosis of aspiration pneumonia. The patients' basic health information, length of hospital stay (LOS), and oral health assessment tool (OHAT), functional oral intake scale (FOIS), pneumonia severity index, and clinical frailty scale scores were recorded. Patients were divided into two groups based on their median OHAT scores, and intergroup changes were analyzed as a function of time. The relationship between the LOS, FOIS score upon discharge, and OHAT scores at admission was examined using multiple regression analysis.

RESULTS

Of the 89 participants (52 were men, with a mean age of 84.8 ± 7.9 years), 75 were discharged. The patients' oral health was measured weekly for 3 weeks after the initial assessment via the OHAT, wherein the median score was 7, with a significant between-group difference. Moreover, OHAT scores improved within both groups throughout their stay. OHAT scores at admission were independently associated with the LOS (B = 5.51, P = 0.009).

CONCLUSION

Poor oral health status at admission was associated with longer hospital stays. Both the high- and low-OHAT groups showed OHAT score improvements. Oral health status is critical in preventing the onset of and treating aspiration pneumonia.

Physical, oral, and swallowing functions of three patients with type a xeroderma pigmentosum: a report of three cases

BACKGROUND

Xeroderma pigmentosum (XP) is an extremely rare and severe form of photosensitivity. It is classified into types A-G or V according to the gene responsible for the disease. The progression and severity of symptoms vary depending on the type. Although dysphagia caused by decreased swallowing function and dental malposition due to stenosis of the dentition in the facial and oral regions is common, it has not been reported in detail. We report three cases of type A XP, in which central and peripheral neurological symptoms appeared early on and progressed rapidly. We describe the oral function of these patients, focusing on the swallowing function and dentition malposition.

CASE PRESENTATION

Two males (27 and 25 years old) and one female (28 years old) presented with diverse neurological symptoms. We focused on the relationship between the changes in swallowing and oral functions and conditions due to decline in physical function. Some effects were observed by addressing the decline in swallowing and oral functions. In particular, a dental approach to manage the narrowing of the dentition, which was observed in all three patients, improved the swallowing and oral functions and maintained the current status of these functions.

CONCLUSIONS

In type A XP, early decline in oral and swallowing functions is caused by the early decline in physical function, and it is necessary to monitor the condition at an early stage.

Kinematic analysis of chewing and swallowing function after cervical spine surgery

PURPOSE

Although movement of the hyoid bone is different for masticatory swallowing and liquid swallowing in normal subjects, it has not been studied after cervical spine surgery. Therefore, we analyzed the swallowing dynamics of masticatory swallowing in anterior cervical spine disease surgery using foods that require chewing close to actual meals.

METHODS

A day before and one week after the surgery, a videofluoroscopic swallow study (VFSS) was performed, and the distance of hyoid bone movement in the anterior and superior directions, amount of opening of the upper esophageal sphincter (UES), time of passage through the pharynx, number of swallows, and amount of pharyngeal residual were measured on the VFSS images during a masticatory swallow of corn flakes. The swallowing function was evaluated by DSS (dysphagia severity scale) and FOIS (functional oral intake scale). Imaging software was used for the measurements.

RESULTS

Postoperative hyoid movement during masticatory swallowing was not significantly different for anterior movement but significantly limited in upward movement (p = 0.002); UES opening volume was significantly decreased (p < 0.001), and bolus residue was significantly worse (p < 0.001), compared to preoperative. The pharyngeal transit time was not significantly different; the number of swallows increased (p < 0.001), along with DSS (p < 0.001) and FOIS (p < 0.001), with significant differences before and after surgery, indicating worsened swallowing function.

CONCLUSIONS

Swallowing function worsened in masticatory swallowing after surgery for cervical spine disease, mainly due to the restriction of upward movement of the hyoid bone and the resulting increase in pharyngeal residuals after swallowing.

Relationship between the jaw-closing force and dietary form in older adults without occlusal support requiring nursing care

In clinical practice, we encounter cases wherein older adults lacking occlusal support consume foods requiring mastication and adequate swallowing function. This study investigated the relationship between jaw-closing force (JCF) and dietary form in older adults without occlusal support requiring nursing care. This prospective cross-sectional study included 123 older adults requiring nursing care who lost their molar occlusal support and consumed food orally without dentures. JCF was defined as the force required for crushing food with the edentulous ridges or with the tooth and edentulous ridge while closing the mouth. Participants were classified into four groups based on the International Dysphagia Diet Standardization Initiative framework for recommended dietary forms. Basic information was collected, and tongue pressure and JCF were measured. Differences in JCF were analyzed using one-way analysis of variance, while factors related to dietary form were evaluated using ordinal logistic regression analysis. Significant differences in JCF were observed among the four groups. Factors such as the Barthel Index, tongue pressure, and JCF were dietary form-related. Our findings suggest that older adults requiring nursing care tend to have higher JCF when consuming meals requiring mastication. Therefore, JCF could serve as an index for determining appropriate dietary forms in this population.

Tongue Strength of Older Adults Requiring Long-Term Care Varies throughout the Day

Physical performance shows approximately 30% diurnal variation; however, diurnal variation in oral function remains unclear. This study aimed to determine the diurnal variation in oral and swallowing function in older adults requiring long-term care. The participants included 13 adults aged >60 years (3 men and 10 women, mean age: 77.2 ± 6.3 years, age range: 62-90 years) requiring long-term care. Tongue strength (TS) and oral mucosal moisture were measured as indices of oral and swallowing function, while hand grip strength was measured as an index of general muscle strength. The patients were asked to participate in a "test" after breakfast, lunch, and dinner on the same day. Multilevel linear regression analysis was used to examine diurnal differences in each item. Multilevel linear regression analysis with adjustment for age and sex revealed that TS was significantly higher at noon (p = 0.001) than in the morning. Therefore, caregivers who provide support during meals to older people requiring long-term care should consider the possibility of swallowing function differing according to the time of the day. In conclusion, it may be beneficial to establish a nutritional therapy that accounts for the diurnal variation in TS.

Usefulness of a newly developed endoscope for the observation of the posterior tracheal wall

Objective

Videoendoscopic evaluation of swallowing is an objective swallowing function evaluation method used in dysphagia rehabilitation. However, it is anatomically difficult to detect the entry of foreign substances through the posterior tracheal wall using a conventional endoscope (CE). In this study, we developed an endoscope that can observe the posterior tracheal wall and investigated its reliability and validity in healthy adults.

Methods

Twenty healthy adults were included. The trachea was observed from inside the larynx using a CE and a portable, flexible two-step angulation endoscope (two-AE) with a two-step curved shaft tip. The visibility of the anterior and posterior walls was recorded. The time from the endoscope tip entering the larynx to the posterior tracheal wall was measured. Additionally, discomfort events were assessed after the examination. McNemar's test and a paired t-test were used for statistical analysis. Kappa coefficients and concordance rates were calculated.

Results

The anterior tracheal wall was observed using both endoscopes. The posterior tracheal wall was significantly observed in 18 participants with the two-AE (p < .001), compared to only three of 20 participants with the CE. The time to observation of the posterior tracheal wall for examiners 1 and 2 was 13.3 ± 6.5 and 12.0 ± 6.7 s, respectively, with no difference between groups (p = .400). The kappa coefficients of examiners 1 and 2 and between the examiners were 0.444, 0.643, and 0.643, respectively, with concordance rates of 90%, 95%, and 95%, respectively.

Conclusion

Regardless of the examiner's years of experience, we observed that the two-AE could observe the posterior tracheal wall.

Level of Evidence

Step 5.

Effects of tongue right positioner use on tongue pressure: a pilot study

The effectiveness of the tongue right positioner (TRP) use on oral and swallowing functions remains unclear. To investigate the effects of TRP use on tongue function in patients with dysphagia. This interventional study included eight participants with dysphagia who visited a university dental hospital. The measurement variables included tongue pressure (TP) as the primary outcome and lip and tongue movements, peak nasal inspiratory flow, and changes in the tongue and suprahyoid muscle regions on ultrasonography as the secondary outcomes. Each participant was asked to use a TRP for at least 8 h every night for 2 months. The measurement variables before and after the intervention were compared using the paired t test and Wilcoxon signed-rank test. TP after intervention (31.5 ± 13.1 kPa) was significantly higher than that before intervention (23.0 ± 13.4 kPa), while other measurement variables did not significantly improve. Numerous exercises have been suggested to improve TP; however, most require patients' adherence to instructions. In contrast, although participants did not perform active exercises, most participants in this study observed an improved TP. Our findings show that TRP can greatly improve TP after 2 months of usage.Trial registration number: University Hospital Medical Information Network Clinical Trials Registry (UMIN000040253, date of first registration: 27/04/2020).

Association between Tongue Pressure and Jaw-Opening Force in Older Adults

Tongue pressure (TP) is used to assess tongue muscle strength and is related to function and frailty. While performing TP, it is necessary to elevate the tongue and oral floor by contracting the suprahyoid muscles. However, the association between TP and suprahyoid muscle strength remains unclear. Accordingly, this study investigated the relationship between TP and jaw-opening force (JOF), an indicator of suprahyoid muscle strength. This cross-sectional study included 88 independent community-dwelling participants aged ≥65 years. Age, sex, and the number of remaining teeth were recorded. Ultrasonography was used to evaluate the cross-sectional area of the tongue and geniohyoid muscle, as representatives of the suprahyoid muscles. Sarcopenia was diagnosed based on appendicular skeletal muscle mass index, handgrip strength, and gait speed. Multiple regression analysis was performed with TP as the dependent variable. TP was significantly associated with JOF (β = 0.371, p = 0.003). This study revealed that decreased TP was associated with a decline in JOF and suprahyoid muscle mass in older adults. Thus, low TP may be associated with decreased JOF. Prevention of the weakness of the suprahyoid muscles and maintaining TP may also contribute to the prevention of frailty associated with TP.

At-Home Orthodontic Treatment for Severe Teeth Arch Malalignment and Severe Obstructive Sleep Apnea Syndrome in a Child with Cerebral Palsy

Children with cerebral palsy typically have severe teeth arch malalignment, causing swallowing and respiration dysfunction. Malalignment in cerebral palsy, especially in children, worsens dysphagia and respiratory disorders; sometimes, it is also noted with obstructive sleep apnea. However, no study has reported on the improvement in obstructive sleep apnea after at-home orthodontic treatment in children with cerebral palsy. We herein present a pediatric case of cerebral palsy wherein obstructive sleep apnea improved with at-home orthodontic treatment for malalignment. We administered at-home orthodontic treatment to a 15-year-old boy with quadriplegia, due to spastic-type cerebral palsy, having no oral intake, obstructive sleep apnea, and teeth arch malalignment. After treatment, a decline in the severity of sleep apnea was observed. Perioral muscle hypertension and oral intake difficulties cause maxillary protrusion, narrowed teeth arch, and tilting of teeth in children with cerebral palsy. We expanded the oral cavity volume by orthodontic treatment to relieve muscle hypertension and correct the tongue position, thereby remarkably improving obstructive sleep apnea. Our findings suggest that at-home orthodontic treatment for malalignment effectively improves perioral muscle hypertension, glossoptosis, and obstructive sleep apnea.

Jaw-Opening Force as a Useful Index for Dysphagia: A Cross-Sectional and Multi-Institutional Study

<b><i>Introduction:</i></b> Jaw-opening force (JOF) can be a potential screening tool for dysphagia. However, confounding variables such as comorbidities or physical and oral functions that are associated with the physiology of swallowing have not previously been examined. Adjusting for these variables could reveal the relationship between JOF and dysphagia and indicate whether JOF is an independent factor associated with dysphagia. We therefore aimed to assess the efficacy of using JOF for dysphagia screening in this multi-institutional study. <b><i>Methods:</i></b> Community-dwelling older adults over the age of 65 years (<i>N</i> = 403) who visited the university dental hospitals and participated in health surveys (mean age ± standard deviation, 77.1 ± 7.0 years; range, 65–96 years) between November 2018 and January 2020 were included in this study. The JOFs of all participants were measured. The measured JOF was compared with the presence of dysphagia, which was defined using the Functional Oral Intake Scale and the Eating Assessment Tool-10. <b><i>Results:</i></b> Multiple logistic regression analysis revealed that the presence of dysphagia was independently associated with JOF, calf circumference, and dependence after adjusting for age and sex. <b><i>Discussion/Conclusion:</i></b> Decreased JOF can be a risk factor for dysphagia in older adults.

Cloning, gene structure and dietary regulation of the type-IIc Na/Pi cotransporter in the mouse kidney

We have demonstrated previously that the type-IIc Na/Pi cotransporter is a growth-related renal Na/Pi cotransporter that is highly expressed in kidney of the weaning rat. In the present study, we investigated type-IIc Na/Pi cotransporter function further by cloning the mouse gene and characterizing the corresponding protein. The mouse type-IIc transporter amino acid sequence shows a high degree of similarity to the human (86%) and rat (95%) type-IIc Na/Pi-cotransporters. The mouse gene contained 14 exons and mapped to chromosome 2. The DNA sequence upstream from exon 1 is GC rich. The upstream region does not contain an apparent TATA box, but does contain two dietary Pi-responsive elements, which are potential binding sites for the transcription factor micro E3 (TFE3). Microinjection of mouse type-IIc cRNA into Xenopus oocytes demonstrated sodium-dependent Pi cotransport activity. The affinity for Pi was about 200 microM in 100 mM Na. Feeding adult mice fed a low-Pi diet increased the expression of type-IIc protein in the apical membrane of renal proximal tubular cells. Hybrid depletion studies suggested that the type-IIc transporter contributes to about 30% of Na/Pi cotransport in the kidney of adult mice fed a low-Pi diet. The present study suggests that the type-IIc Na/Pi cotransporter is a functional of renal Pi transporter in adult mice fed a low-Pi diet.

Regional differences in myocardial work of the left ventricle in patients with idiopathic dilated cardiomyopathy: Implications for the surgical technique used for left ventriculoplasty

OBJECTIVES

In this study we measured regional myocardial work of the left ventricle in patients with dilated cardiomyopathy and examined the existence of regional differences in myocardial work.

BACKGROUND

Left ventriculoplasty aims to improve the ejection fraction by excluding a region with decreased wall motion and decreasing wall tension. If regional differences in myocardial work are present, left ventriculoplasty will be more effective when a region with decreased myocardial work is excluded.

METHODS

The study group consisted of 10 patients with idiopathic dilated cardiomyopathy. Regional work of the ventricle normalized to a unit volume of myocardium (RWM) is given as follows: RWM = -integral sigma(d)[ln(1/H)], where sigma is mean wall stress, and H is wall thickness of the region. After right-sided catheterization, left ventricular pressure was measured with a 3F micromanometer catheter. Echocardiography was performed simultaneously, and a short-axis view of the left ventricle at the level of the papillary muscles was obtained. The derived M-mode image was recorded with left ventricular pressure. sigma-ln(1/H) relations for the ventricle were delineated, and regional work of the interventricular septum and posteroinferior wall were determined. Relationships between regional work of the myocardium and wall thickness, interventricular septal regional work of the myocardium and right ventricular systolic pressure, and right ventricular ejection fraction were also studied.

RESULTS

Interventricular septal regional work ranged from -0.84 to 3.34 mJ/cm3 (0.74 +/- 1.51 mJ/cm3). Posteroinferior wall regional work ranged from 1.59 to 4.29 mJ/cm3 (2.77 +/- 0.86 mJ/cm3). In the study group, interventricular septal regional work was lower than posteroinferior wall regional work (P <.05). In 8 of these 10 patients, interventricular septal regional work was lower than posteroinferior wall regional work. In the other 2 patients, conversely, interventricular septal regional work was higher than posteroinferior wall regional work.

CONCLUSIONS

The existence of differences in regional work between the interventricular septum and the posteroinferior wall suggests the importance of the evaluation of regional work in the selection of an effective treatment for dilated cardiomyopathy.