Dysphagia 17:235241 (2002) DOI: 10.

1007/s00455-002-0063-6

Analysis of Feeding Function and Jaw Stability in Bedridden Elderly

Fumiyo Tamura, DDS, PhD, Miki Mizukami, DH, Rika Ayano, DDS, PhD, and Yoshiharu Mukai, DDS, PhD
Department of Hygiene and Oral Health, Showa University School of Dentistry, Tokyo, Japan

Abstract. The purpose of this study was to analyze the relationship between jaw stability and the feeding function of 53 bedridden elderly dysphagic patients. Investigations included a questionnaire on daily life activities and meals, oral examinations, functional tests for feeding ability, and assessments of feeding function during the meal. The results of intraoral examination of this patient population for jaw stability revealed that 34.0% of individuals had posterior support for occlusion regardless of whether they had natural teeth or dentures. Thus, the number classied as having mandibular stability (ST) was 18 and that with no mandibular stability (NST) was 35. In a Repetitive Saliva Swallowing Test (RSST), 83.3% of the NST group and 40.0% of the ST group were unable to swallow more than 3 times within 30 seconds. In a water swallowing test, 91.4% of the NST of group was unable to swallow 15 mL of water by a single swallow, while 40.0% of ST group was capable. The results suggest that jaw stabilization by occlusion with the posterior teeth or dental prosthetics is important to feeding function, particularly swallowing. Key words: Bedridden elderly feeding function Jaw stability Deglutition Deglutition disorders.

Ingestion of food after the recognition phase consists of a series of movements beginning with the capture of food with the lips and transfer to the esophagus [1]. Dysphagia is linked by most clinicians with abnormal

This study was supported by the Japanese Ministry of Health and Welfare as a part of research eort on elderly health care in 1997. Correspondence to: Fumiyo Tamura, D.D.S. Ph.D., Department of Hygiene and Oral Health, Showa University School of Dentistry, 1-5-8 Hatanodai Shinagawa-Ku, Tokyo, 142-8555 Japan. Telephone: 81-3-3784-8172, Fax: 81-3-3784-8173, e-mail: fumi@ dent.showa-u.ac.jp

reex swallowing and is a consequence of various diseases. The symptoms of abnormal reex swallowing are related to the voluntary aspects of ingestion which occur prior to and during the swallow initiation. However, reex swallowing also contributes to important events in the initiation of swallowing, including raising of the hyoid bone by the suprahyoid muscles and lifting of the larynx. To complete these consecutive tasks, the mandible needs to be stabilized in the desired position. In the elderly, the positions of the larynx and the circular cartilage have become lower due to eects of aging of the suprahyoid muscles [2,3]. If lifting of the hyoid bone and larynx for swallowing initiation is not sucient, the dangers of suocation and aspiration are increased. These unfavorable anatomical changes that occur with aging along with loss of the posterior dentition result in an unstable jaw relationship. Therefore, swallowing function during the oral stage would be aected as the teeth are used to stabilize the mandible [4]. Although the eects of aging on swallowing function have been reported [59], the inuences of oral anatomical changes on feeding function are unknown. Several investigations have discussed meals for elderly individuals but have focused primarily on the relationships of food consistency or mastication and not on swallowing [1013]. Although several screening methods for dysphagia have been reported by Nilsson [9], Adeline [14], and Zimmermann [15], these methods suer from technical problems such as possible water ow into the pharynx during evaluations and lack of evaluation standards. Therefore, two individual tests were selected for the evaluation of dysphagia in the present study. A Repetitive Saliva Swallowing Test (RSST) was developed as a safe screening method for the swallowing function in clinical settings. In an aspiration screening of adults diagnosed with cerebral vascular accidents (CVA), Saitoh et al. [16,17] re-

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F. Tamura et al.: Analysis of Feeding Function and Jaw Stability Table 1. Major diagnosis of study participant Number of subjectsa Respiratory disease Stroke Circulatory disease Kidney disease/diabetes Dementia/mental disorder Bone disease Parkinson's syndrome Multiple sclerosis Others
a

ported that the normal range of function measured with the RSST is more than three cycles of swallowing within 30 s. The same evaluation standard was used in the present study to dene normal function. Another standard used in evaluation of swallowing function, the duration of time until onset of rst swallow, was determined in a previous study as less than 6 s using the RSST [18]. Oguchi et al. [19] investigated the correlation between the RSST and videouorography (VF) in association with aspiration. Using a standard of three swallowing cycles within a 30-s period, they demonstrated a high correlation between aspiration and RSST. The RSST can begin with dry swallowing or with articial saliva, making this test suitable for patients with a high risk of aspiration. Thus, the RSST is an excellent screening method for swallowing functions. Evaluation by the water-swallowing test requires 30 mL of water. When this test is carried out in patients with a high risk of aspiration, choking, suffocation, and consequent general stress are signicant risks [19]. In this study, the amount of water was decreased to 15 mL which has been reported to be acceptable for this patient population [20,21]. Notwithstanding the possibility that silent aspiration may be overlooked even when the quantity of water is reduced [19]. This method is frequently used as a convenient clinical assessment [22]. The purpose of the present study was to investigate the relationship between feeding function and the mandibular stability gained from the occlusion of the posterior teeth. The results of this research are intended to clarify the importance of the dentition and prosthetic restorations with swallowing events.

2 33 3 2 11 2 3 1 19

Most subjects had multiple diseases.

Table 2. Questionnaire items 1. 2. 3. 4. 5. Diagnosis Fallen day (for CVA) Complications Disturbance of motility Question on the meal (1) Feeding method (2) Reason for tube feeding (3) Continuation of feeding condition (4) Degree of assistance for feeding (5) Place of the meal 6. Height, weight, blood examination (protein, albumin, CRP) 7. Medical history for past year (1) Pneumonia (2) Suocation (3) Dehydration (4) Fevers 8. General daily life (1) Activity of daily living (ADL) (2) Percentage of degree in a sitting position 9. Assistance required for daily activities (1) Rolling ability on bed (2) Transfer from the bed to the chair (3) Excretion 10. Motivation to communicate 11. Degree of understanding or communication 12. Degree of expressiveness of communication 13. Physical rehabilitation 14. Oral health care (1) Presence of dentures (2) Condition of teeth, gingiva, and other soft tissues (3) The time required for oral health care (4) Oral hygiene armamentarium used (5) Ability for mouth wash 15. Dental history presented by referring dentist

Subjects and Methods

The subjects were 53 bedridden individuals housed under general hospitalization or in an elderly health care center (13 men, 40 women, average age 78 years). More than half were ranked B or C in daily life activity according to the classication of the Japanese Ministry of Health and Welfare [23]. The B or C classication implies the subjects were bedridden. All of the subjects in the study were diagnosed with dysphagia, and the primary medical diagnosis of each patient is shown in Table 1. Each subject was evaluated with a questionnaire describing daily life activities, oral health care, and diet (Table 2). A rehabilitation physician, four dentists, a speech pathologist, and a dental hygienist comprised the team that clinically examined each patient's oral function and condition (Table 3). The examination included evaluation of occlusal support by natural dentition or removable prosthetics [24], the type of diet, the RSST [16,17], a water-swallowing test [22], and an observatory evaluation of feeding function during a meal. The criterion of the jaw stability

was the ability to achieve posterior occlusal contact with natural dentition or prosthesis under an appropriate occlusal guidance. Patients were categorized as having mandibular stability (ST) or no mandibular stability (NST). The RSST was completed by the speech pathologist, and the rehabilitation physician administered the water-swallowing test. Evaluation of feeding function for subjects was made by all of the investigators. If the assessments differed, the team conferred to get consensus.

F. Tamura et al.: Analysis of Feeding Function and Jaw Stability Table 3. Clinical examinations 1. Evaluation of oral region (1) Number of remaining teeth (2) Presence of complete or partial dentures; condition of dentures (3) Condition of occlusal dentition to jaw stability (4) Oral dyskinesia (5) Tongue position at the rest (6) Presence of glossitis (7) Range of mandibular opening 2. Evaluation of oral hygiene (1) Dental plaque (2) Dental calculus (3) Tongue plaque (4) Presence of food debris 3. Oral bacteria; Candidadis (1) Palatine (2) Pharynx (3) Tongue 4. Examination of feeding functions (1) RSST (Repetitive Saliva Swallowing Test) (2) Water swallowing test (3) Food Test 5. Videouorography 6. Independent assessment by speech pathologist 7. Assessment during the meal (1) Condition of the sitting position (2) Height of the table (3) Angle of the trunk (4) Angle of the neck (5) Angle of the hip joint (6) Angle of the knee joint (7) Utensils (8) Recognition of meal (9) The quantity of the food in single feed (10) Feeding pace (11) Mouth-hand coordination (12) Suitability of the assistance (13) Lip function during the meal (14) Food bolus transportation with tongue (15) Choking (16) Coughing (17) Raising the jaw during swallowing (18) Saliva swallowing (19) Food consistency (solid, whole, chopped, pureed) Table 4. Standard water-swallowing test (15 mL)

237

Prole Abilities to swallow liquid scored as: 1. Asymptomatic for unlimited swallows 2. No choking for minimum of 2 swallows 3. Choking by single swallow 4. Choking with 2 swallows 5. Choking with any amount of liquid Criteria documented as observed episode Description of the swallowing observation included: 1. The method of liquid intake (gulping, sipping, etc.) 2. Existence of spilling or drooling 3. Time duration Criteria for time duration 1. Normal range: within 5 s in prole 1 2. Critical to abnormal range: over 5 s in prole 1 and prole 2 3. Abnormal range: proles 3, 4, and 5

Results Oral Examination The results of intraoral examination of this patient population for jaw stability revealed that 34.0% of individuals had posterior support for occlusion regardless of whether they had natural teeth or dentures. Thus, the number classied as ST was 18 and NST was 35. The distribution patterns of the ST group having posterior support included two with complete natural dentition, six with missing teeth but stable dental occlusions, six with removable partial dentures, and four with complete dentures. The NST group was edentulous without a stable complete denture or partially edentulous with no posterior antagonist occlusion. Diet The distribution of food consistency for the 41 individuals who had intraoral feeding was as follows: 25 subjects processed solid food, 4 all-rice porridge, and 12 pureed food. When food consistency was considered for the ST and NST groups, the distribution of individuals who could stabilize the mandible (ST) was as follows: 13 subjects processed solid food, 1 all-rice porridge and 1 pureed food. For individuals who had nonstable jaw relationships (NST), the distribution of each subject's diet was as follows: 12 processed solid food, 3 all-rice porridge, and 11 pureed food. Twelve of the 53 subjects required tube-feeding due to severe dysphagia. Function Tests: RSST and Water-Swallowing Test Among functional feeding tests, 22 individuals were able to attempt both the RSST and the water-swal-

The RSST is an assessment of the patient's potential to swallow saliva. It is performed by counting the frequency of swallowing over a 30-s period. The water-swallowing test was begun by giving a total of 15 mL of water in a cup to the subject to swallow. The swallowing behavior was observed and described using the criteria shown in Table 4. Feeding function during the meal was also analyzed. This observation monitored choking and coughing, lip function, and duration from food intake into the oral cavity until swallowing. These data were statistically analyzed by the v2 test to clarify the correlation between subjects with mandibular stability (ST) and those with no mandibular stability (NST). Quantication Theory II was used to examine the sequence relationship of each item [25,26]. Quantied continue data from the RSST were evaluated using Student's t-test for the ST and NST subjects at p 0.01.

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F. Tamura et al.: Analysis of Feeding Function and Jaw Stability Table 5. Comparison of mean value for RSST RSST No. swallows in 30 s Duration for onset of rst swallow (s)
a

lowing test. Thirty-one subjects were unable to be evaluated due to cognitive problems or tube-feeding. The results of the mean value for the frequency of swallowing in 30 s and duration for the onset of the rst swallow are presented in Table 5. The values for ST were 2.80 1.25 and for NST, l.33 1.03. The swallowing frequency value for ST was signicantly greater than the value for NST (Student's t-test; p 0.01). The results of the relationship between swallowing function and mandibular stability are presented in Table 6. When testing swallowing function with the RSST, 83.3% of the NST group (10 of 12) and 40.0% of the ST group (4 of 10) were not able to swallow more than 3 times within 30 s. These values were signicantly dierent (p 0.01), demonstrating decreased function with mandibular stability using the v2 test. For duration until the onset of the rst swallow, 50.0% of the NST group (6 of 12) took more than 6 s, while the number of subjects decreased to 30.0% (3 of 10) for ST. Although more NST subjects had prolonged onset until rst swallow, there was no statistical signicant dierence between the groups. The results of the water-swallowing test demonstrated that 91.7% (11 of 12) of the NST group was not able to swallow 15 mL of water in a single swallow, while the value for the ST group was 40.0% (4 of 10). These values were signicantly dierent by the v2 test (p 0.01). In the water-swallowing test, 41.7% (5 of 12) of the NST group experienced choking during swallowing, but 10.0% (1 of 10) of the subjects in the ST group had a similar experience. The dierences in these results were not signicant. The correlation among mandibular stability was analyzed by the Quantication Theory II method. Four factors that were considered were swallowing frequency, duration until onset of rst swallow, ability to complete the water-swallowing test, and presence of choking during the water-swallowing test. The results indicated that water-swallowing ability exhibited the highest correlation (0.461), followed by the swallowing frequency in RSST (0.371), and coughing during water-swallowing test (0.332). The duration to the rst swallowing in RSST (0.054) had least correlation to the mandibular stability. Feeding Functions During a Meal A total of 39 individuals were evaluated for feeding function during the meal, the results of which are summarized in Table 7. Fourteen were unable to be assessed because of their health condition. During food ingestion, 21.4% (3 of 14) of the ST group and

Total 2.001.35 5.095.25

ST 2.801.25 3.952.59
a

NST 1.331.03 6.04+6.55

Signicantly dierent at p<0.01.

16.0% (4 of 25) of the NST group were not able to close their lips completely. This dierence was not signicant by the v2 test (p 0.01). Only 28.6% (4 of 14) of the ST group showed a delay in food transportation between the time the food entered the oral cavity and swallowing, but this value increased to 52.0% (13 of 25) for the NST group. Again, there was no signicant dierence between the ST and NST groups. Choking during the meal was seen in 40.0% (10 of 25) of the NST group and 28.6% (4 of 14) of the ST group, while coughing during the meal was noted in 32.0% (8 of 25) of the NST group and 21.4% (3 of 14) of the ST group. Neither choking nor coughing yielded statistically signicant dierences by the v2 test. The correlation between mandibular stability and the four feeding functions during the meal were analyzed by the Quantication Theory II method. The four factors included lip functions, delay in food transport, choking, and coughing. The results indicated that the coecients of partial correlation for respective items were 0.242 for the delay in intraoral transportation, 0.212 for lip closing, 0.175 for coughing, and 0.0085 for choking. Coughing and choking had the least correlation to mandibular stability.

Discussion A stabilized jaw relationship is important for intraoral feeding and swallowing, but it is dicult to maintain mandibular stability when the posterior dentition is lost. It is also essential to hold the tip of the tongue on the lingual surfaces of maxillary anterior teeth in order to complete the swallowing event by the elevation of the hyoid bone. However, unfavorable tongue thrust may occur when anterior teeth are lost [27], further decreasing the ecacy of the swallow. Therefore, appropriate dental prosthetic treatment is often necessary to maintain mandibular stability and oral function. Prosthodontic treatment is usually employed for individuals who have complete edentulism or partial edentulism with no op-

F. Tamura et al.: Analysis of Feeding Function and Jaw Stability Table 6. Relationship between swallowing function and mandibular stability (ST) or no stability (NST) (Quantication Theory II)a Number Item 1. RSST: No. swallows in 30 2. RSST: Duration until rst swallow 3. Water-swallowing test 15 mL water, single swallow) 4. Water-swallowing test: presence of choking
a b

239

Category Over 3 swallows Less than 3 swallows Less than 6 s More than 6 s Able Unable No Yes

Total (22) ST(10) 8 14 13 9 7 15 16 8 6 4 7 3 6 4 9 1

NST(12) 2 10 6 6 1 11 7 5

Weight 0.6576 )0.3757 0.0549 )0.0792 )0.8786 0.4100 )0.2388 0.6369

Partial correlation coecientb 0.371432 0.054462 0.461392 0.331886

ST=mandibular stability, NST=no mandibular stability, RSST=the repetitive saliva swallowing test. Multiple correlation coecient: 0.679183.

Table 7. Relationship between assessment of feeding function during the meal and mandibular stability (ST) or no mandibular stability (NST) (Quantication Theory II) Number Item l. Closed lips during food ingestion Category No eect Slight eect Severe eect No eect Slight eect Severe eect No eect Slight eect Severe eect No eect Slight eect Severe eect Total (39) 32 6 1 22 7 10 25 11 3 28 9 2 ST(14) 11 3 0 10 2 2 10 3 1 11 2 1 NST(25) 21 3 1 12 5 8 15 8 2 17 7 1 Weight 0.1606 )1.2113 2.1284 )0.5695 0.1847 1.1238 )0.1903 0.2789 0.5636 0.0539 0.3287 )2.2335

Partial correlation coecientb 0.211700

2. Food transportation

0.242415

3. Choking

0.084970

4. Coughing

0.174868

ST=mandibular stability NST=no mandibular stability. Multiple correlation coecient: 0.343812.

posing antagonist teeth for the remaining dentition. It is very common for care center residents to lose their dentures during hospitalization. It is also a common occurrence for them to discontinue wearing their dental prosthetics long-term [28]. The interrupted use of dentures makes continued use of the prostheses relatively dicult and complicated because of both hard and soft tissue changes. Therefore, it is necessary to motivate bedridden individuals and their caregivers to understand the signicance and the management skills associated with complete and partial dentures. In this study, the majority of individuals (66%) were not able to stabilize the mandible. This subset of patients without a stable dental occlusion, designated NST, provided an opportunity to clinically evaluate

swallowing function. The occurrence of their dierences in occlusal or swallowing forces and the pattern of jaw stabilization were anticipated even for the stabilized patient (ST) as a result of their dierent modes of posterior support. This support included occlusion by natural or articial dentition or dierent numbers of residual teeth. However, the presence of antagonistic contacts with the opposing dentition or substitutes does not necessarily suggest complete orthopedic stability of the mandible. Although all these factors were considered to provide jaw stability in this study, insucient periodontal support, deective occlusal contacts, ill-tting prosthesis, or even occlusal forces can still decrease overall stability of the mandible. Further study is necessary to analyze the degree of occlusal stability for ecacious swallowing.

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F. Tamura et al.: Analysis of Feeding Function and Jaw Stability

With regard to food type, many NST subjects were able to consume ground food. However, no subject from this patient population ate a diet of normal food regardless of the presence of mandibular stability. As an appropriate food consistency was provided to the subjects in this study, the result diers from a previous study of the individuals surveyed at dierent care facilities [18]. There were dierences in subject numbers between ST and NST for the evaluation by functional tests. Ten of 18 ST (56%) subjects participated in the RSST and the waterswallowing test versus only 12 of 35 NST (34%) subjects participated in these functional trials. This deviation was attributed to the ability of the participants. The individuals in the NST group might have been more severely neurologically aected by cognitive and/or sensorimotor impairments than those in the ST group. The importance of mandibular stabilization to trigger the swallowing reex was reinforced by the results of the RSST, which demonstrated better function in both duration of time until onset of rst swallow and the swallowing frequency for the ST group. The waterswallowing test also suggested that the ST group had better function than the NST group. When these two tests were compared, the waterswallowing test was most inuenced by mandibular stabilization. The swallowing reex can be provoked by a certain amount of waterswallowing. However, in the beginning of the waterswallowing test, patients needed to control the water bolus with their tongue because its physical property allows it to ow easier into the larynx compared with saliva. Therefore, restoration of unstable posterior occlusion with complete or partial prosthetics can be important to swallowing function as it prevents tongue thrust. Besides, in the elderly, as swallowing dysfunction may be caused by decreased salivary secretion [2931] due to the inferior displacement of the larynx and hyoid bone following the deterioration of muscular strength [2,3], mandibular stability is also necessary to maintain the larynx and hyoid position as a result of the RSST. Although dysfunction of the tongue, larynx, and pharynx is commonly recognized as a cause of choking, other anatomical conditions within the oral region also inuence tongue movement as well as the swallowing reex. For example, choking is inuenced by the angle of the trunk and neck during the meal [32], indicating the importance of feeding posture. A decrease in muscular ber of the tongue has been measured with age. The loss of functional tissue is most prominent in the tip area of the tongue [33]. Another eect reported with aging is that the tongue

muscle tends to be displaced inferiorly and posteriorly and has been termed a ``dipper-type'' tongue [34]. The resulting loss of tongue function is that the food bolus may possibly remain on the oral cavity oor and not properly transported to the throat for swallowing [34]. As there were no signicant dierences between the ST and NST groups in the evaluation of feeding function during the meal, the ability to utilize tongue muscle to control food bolus did not signicantly eect the swallowing of liquid. However, the mandibular stabilization did inuence the delay of transport of food to the esophagus, which is completed by vermicular motion of the tongue. As the formation and transportation of food bolus is closely related to tongue function, further study is necessary to analyze bolus formation with this dysphagic population. This study could not prove that the mandibular stability with dental prosthesis improved the oral functional status in the NST group. We should evaluate the prognosis with a dental prosthetic approach for these patients in the future.

Conclusion On the basis of the results of this study, posterior support of the occlusion with either natural dentition or a prosthetic, such as dentures, to stabilize the jaw relationship has the potential to play an important role in the oral function associated with feeding and swallowing processes, especially in the dysphagic population. Occlusal stabilization of the mandible was most signicant when transporting food through the oral cavity prior to swallowing. Patients with no mandibular stability also experienced greater diculty in swallowing liquids. This study is a screening investigation, as the information is based on limited subjective measurements. Further investigations are needed to explore the relationships between swallowing function and specic oral conditions, including types of dental occlusions, the number of residual teeth required for stability, and the ecacy for complete dentures in improving swallowing function.
Acknowledgments. The authors thank the sta and individuals at The Brain Blood Vessel Obstacle Research Institute, Mihara Memorial Hospital, and Tennohkai Amamoto Hospital. The excellent technical assistance of Dr. Junko Fujitani at the Department of Rehabilitation, Tokyo Metropolitan Rehabilitation Hospital, is gratefully acknowledged. Finally, the authors also thank Dr. Shiro Suzuki and Dr. Daniel Givan at the Department of Prosthodontics and Biomaterials, University of Alabama at Birmingham School of Dentistry for their fruitful discussions.

F. Tamura et al.: Analysis of Feeding Function and Jaw Stability

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