Lemon Swab

Music:
[0:00] Music

Speaker1:
[0:16] I'm Emily.

Speaker0:
[0:17] And I'm Eva.

Speaker1:
[0:18] And you're listening to Speech Talk.

Speaker0:
[0:20] We're your research-based book club so you can stay informed and do evidence-based practice in practice.

Speaker1:
[0:27] So let's get talking. Today, we are doing a deep dive into the world of oral care for speech-language pathologists and anyone else who really wants to join in the oral care things fun.

Speaker0:
[0:41] Yeah, I know. I always think about that. I know we talk about my mom a lot because she's a dentist, but she's always down to join the Oral Care Fund talk.

Speaker1:
[0:49] I mean, you have to stop talking about your mom without bringing her here. I need to talk to your mom. I need to jive with her with some oral care stuff.

Speaker0:
[0:59] She'd love that. In all honesty, she would.

Speaker1:
[1:02] I bet she would.

Speaker0:
[1:03] So we're going to be getting into the pros and cons of oral care products for our patients. Buckle up, you guys, because we're about to talk toothbrushing. which on that note i just want to go back to why we wanted to do this episode i was in a patient's room and the family was there and they're so wonderful they're so attentive their mom uh couldn't perform oral care really advanced dementia and so they were doing all her oral care for her, and the daughter is brushing her teeth with lemon glycerin swabs and she was like yeah i got trained by a speech therapist and how to do this. I was like, oh, that's so great. You're doing oral care. It looks like you're doing a really good job. And I can't remember if it was like later that day or the next day that I just like facepalmed because I was like, just sitting there like coating her mom's teeth in tiny amounts of lemon juice, basically. Like that can't be good. There's so much acid in it. And so Emily and I were talking and I was like, you know, we see so many different types of like dental swabs, including lemon glycerin ones being used in geriatric care that we should look into if there are comparative benefits or harms of these different products.

Speaker1:
[2:17] But, and literally I had never even considered them. Like the thought never crossed my mind. It was like, maybe these are not great for your teeth. And so you, Eva, were like, have you ever thought about lemon? I was like, literally no.

Speaker0:
[2:31] Bro, have you ever thought about lemon glycerin swabs?

Speaker1:
[2:35] No, I didn't know it went that deep. But Eva, you take us there. So many of our patients can't do the traditional tooth brushing due to safety and comfort. So they have limited oral control. They might struggle to hold liquids in their mouth. They might lose the toothpaste foam. They could have trouble rinsing the water from one cheek to the other or worse mouthwash. And they can lose that anteriorly through their lips or even worse posterior behind the back of their tongue. So for patients with difficulty in the lingual and buccal coordination, they may have a hard time spitting their toothpaste out or they'd be making a giant mess. And it can be very time consuming for the patient and the aide. So I want to make sure the entire process is as easy for all involved as possible.

Speaker0:
[3:34] Yeah. I actually recently did an eval with a patient for oral care because they had advanced cognitive problems and were struggling with liquids. And I was like, okay, we're going to do toothbrush, just dipped in mouthwash to see if you can do that. And I was like, okay, now great. Here's some mouthwash. Rinse. And she straight drank it. It was wild. So that's also something important when you're choosing what's an appropriate oral care product. Just remember, some people drink mouthwash. Tint, bat knife.

Speaker0:
[4:13] No. Okay. So, yeah, I know. To look at the ins and outs of oral hygiene product options, we looked at a research article titled, deliciously titled, I should say, Hospital Mouth. Dental aids may cause dental erosion. I just, I love that hospital mouth that gets me. It was written by Mermin et al. And they assessed the potential, potential erosive effects of different oral care products. The researchers compared four different ones by soaking cow's teeth in them. And then they left the cow's teeth in each solution for like four hours and looked at the teeth for softening and surface damage. And whenever I think about like that soaking of cow's teeth, I just imagine them trying to get like research IRB approval for human teeth. And they're like, no, where are you going to get all these human teeth from? And they're like, dang, what about cow's teeth? That's just like how it, I think about it every time.

Speaker1:
[5:11] I love your train of thought. Okay, so what they found, that two of the ones that they tried really didn't cause that much damage or that what damage wasn't substantial. The Casasol chewing tablets and Dentist swab sticks. So just the foam, nothing on them. But the lemon glycerin swabs cause significant softening and surface changes on the teeth due to the citric acid content.

Speaker0:
[5:40] Yeah, so the research highlights that oral care products with citric acid are essentially the most corrosive and their damage can't easily be repaired because of the way citric acid damages teeth.

Speaker1:
[5:52] Yeah, and we have to remember in these kind of research constraints that we have to take it with a grain of salt, right? They're soaking the cow's teeth, right? Cow's teeth, they're not human teeth, so they're probably already thicker than our teeth, hopefully. Um but they're soaking big cows big teeth it's huge um so they're soaking them for extended periods of times which obviously nobody's doing that in nobody's even doing a fraction of that in our care practices you'd

Speaker0:
[6:25] Have to like hold your teeth in like a cup of like lemon-based solution just like to your mouth just constantly drinking lemon juice.

Speaker1:
[6:34] So, again, that's definitely not happening. But the repeated exposure in general, it can negatively impact the patient's teeth, especially if they have dry mouth or pre-existing erosion. So this is just an added risk for our patients with dry mouth or even people with consistent open oral posture. They just have constant drying and excess bacteria and less of the good bacteria that's supposed to be there to protect your teeth.

Speaker0:
[7:06] Yeah. All it goes back to that, like, lack of sufficient saliva flow to create a healthy oral biome, you know? So what are we going to do with this research? First of all, our clinical judgment is always key. Use your expertise to choose the appropriate tools. It's not to say that lemon glycerin swabs aren't helpful. It could be helpful for gustatory stim or saliva stimulation. But then again, you know, maybe the bulky foam swabs could be inappropriate for if you have patients who like bite down really hard. I had someone almost like chew off the foamy part of one of those like lollipop foam swabs.

Speaker1:
[7:51] And the pure panic that just sets in. It's like, get it out. Get it out.

Speaker0:
[7:55] I know. And their jaw like locked up. And you're just trying to like pry a finger in there to, you know, like, oh my God. And if my patient chokes on foam, there's nobody else who was doing that. It was me. And it's like- 100% my fault.

Speaker1:
[8:09] It's just like, you have to be like brave enough to stick your finger in their mouth. but you're also like so scared of just

Speaker0:
[8:13] Like I saw what they did to the dentist swab I don't want that to happen to me like.

Speaker1:
[8:19] Come on come on be nice just spit it out

Speaker0:
[8:21] Exactly and again we were looking at different alternatives to regular toothbrush but that isn't safe if they can tolerate a regular toothbrush and do that because that's kind of the best one that's really in terms of oral health and taking care of teeth. Real toothbrushes are the best. And so for some of those oral impairments though, maybe toothpaste isn't appropriate, maybe mouthwash is better. None of these tools are wrong. The goal is to find out what is the right one for your patient.

Speaker1:
[8:52] Yeah, the only wrong care is no care.

Speaker0:
[8:55] Oh my God, I love that. The only wrong care is no care.

Speaker1:
[9:00] Trademark, officially. Absolutely. So we want to find out the best oral care practices for our patient.

Speaker0:
[9:07] If you're trying to figure out like how to work this into your session, oral care can be a dysphagia session. That doesn't always have to be like eating and swallowing.

Speaker1:
[9:16] We're teaching our caregivers how to provide proper oral care. We're teaching the patient how to do their oral care. We're teaching them how to manage oral stimulus. Maybe we're teaching them how to tolerate that oral stimulus. Maybe it's sensory stimulation, brushing. We're using the toothbrush or the oral swab to provide resistance in our dysphagia. So there's a lot of different ways that you can incorporate. Also, as a prep session, if you want to be doing oral trials, having a clean oral cavity is important And that is a part of a skilled service, right? So we are providing skilled services by doing oral hygiene.

Speaker0:
[10:02] Oh my God, so many jazz hands for all the things you just said. That's like, that just brings up so much stuff in my mind. You know, one, the number of dysphagia sessions where I was going in to like feed somebody and they opened their mouth and I was like, oh God, we got to get what's in there out before we can even consider eating. So that 100% counts because we're making sure that there is a safe oral cavity for continuing with a feeding-based session. And I know sometimes some places can be kind of sticky around what's ST versus OT. I personally am of the school of thinking that I'm like, hey, making sure there's a clean oral cavity is a part of eating and we should be working together with our OTs, but that doesn't mean that we can't dip our toes in the pool, so to speak. And God, there was something else you were saying. Oh yeah, just about the process and the things that we can be training. I have a patient with a lot of anterior loss right now, and we've been doing labial strengthening exercises, so she doesn't lose liquid. So practicing with her mouthwash is a great opportunity for us to test those oral motor skills that are also helping her keep her soup in her mouth and her coffee in her mouth, you know? But we're just also taking the time to do a little cleaning. Yeah, okay, let's keep moving. Inventory are options.

Speaker0:
[11:28] There's so many random things that are like stuffed in cabinets and closets at work.

Speaker0:
[11:36] In the next to the linen cabinet, there's a storage cabinet, there's tenta swabs, there's lemon glycerin swabs there's toothbrushes there's the denture glue there's all all the oral stuff is in there and then in the rehab gym there's like all kinds of little goodies squirreled away so if you have the time really just see what's available at your facility and if there's something you really want see if you can get it ask your dor there's.

Speaker1:
[12:03] So many times where something is just easier and available to get. And my, and my DOR is pretty good about like, I have one patient who has CP and kind of goes back to what you were saying earlier about OT versus speech. And this particular patient was having like a lot of sensory issues about teeth brushing. And I was like, you know, I think this is better suited for the ADL side of things with OT. I'm going to hand it over to her and the DOR was able to get them like baby toothbrush and baby toothpaste just to give them that different flavor, something that's more tolerable, even softer. So after trialing and therapy, that'll be something the facility maintains for that client. But because, you know, I, I, I'm bragging a little bit. I have a positive, I have a positive team. So they kind of, they put themselves out to purchase those things, but it does. I digress. That could be a, a, a tricky situation for a lot of people putting, like, that's a cheap example, but it can get, can get tricky with some of those like, uh, oral STEM things.

Speaker0:
[13:22] Yeah, but I think that also transitions into our next point for exploring alternatives as well, considering modified toothbrushes, like a kid-sized toothbrush, if that's comfortable and tolerable. Um, my OTs have taught me about these like awesome foam tubes where it's a foam cylinder that has a hole through the center, a regular toothbrush, but the patient can't hold it because they have four hand, um, whether it's like they're over-contracted or they can't close their hand enough, gives them the opportunity to hold something larger. So the toothbrush head fits fine, but they need a giant grip, you know, hit up your OTs for that, for an alternative.

Speaker1:
[14:01] Yeah there I love I love talking with OTs especially about ADLs because I feel like so often we do like a verbal side of things we're like so tell me about your oral care and they're like what uh brushing my teeth that's fine I know how to do that and then like the OT was like no girl I tried to brush his teeth or I tried to do this ADL and they could not figure out for a second third step so oh

Speaker0:
[14:26] Yeah man the sequencing for tooth brushing I was literally talking about this today. I was like watching somebody try to see what, watching to see what someone does with a tube of toothpaste blows my mind. Like the cap has to come off. You have to squeeze it onto the toothbrush. And then the cap goes back on. And sometimes that is too much.

Speaker1:
[14:45] And honestly, it's too much even for my husband. And we have like that like gross cap going back on like crusty tooth. It's like, I'm like, Daniel, this is this is unacceptable. We are adults.

Speaker0:
[15:02] Daniel, you're under the bus now. Emily threw you there. I'm so sorry.

Speaker1:
[15:06] Officially welcome to the podcast

Speaker0:
[15:08] Okay um wow we have just been really naturalistically hitting each of the points we wanted to talk about the next one was collaboration collaboration's king and we've talked a lot about what to do with our ot's i think one thing we didn't uh touch on was, strategizing with positioning i have a lot of patients who i get them upright we're like okay we're going to eat or brush teeth. And then they're slouching back down. They're falling left, right. They don't have maybe enough arm strength or support to appropriately transition the toothbrush around or to their mouth. And getting the good co-treat in can teach you so much about that process.

Speaker1:
[15:51] Yeah. And co-treats are hard, especially in the sniff setting. I don't know, Eva, because I'm contract, but you are in-house. Does your facility allow co-treats with ot

Speaker0:
[16:00] We do we do work in with each other a lot when it comes to like you know stuff that is out of my depth or when my co-workers are like hey i noticed this really weird thing when we were positioning uh you know transitioning out of bed into wheelchair and they were sitting up for their meal i don't know if this is positional or if this is maybe a dysphagia thing so we'll like go in together and try like it's food coming out of their mouth because they don't have the neck and trunk posture so like their head is just constantly down and they're like drooping and stuff is coming out or is it because they can't hold their mouth together you know so yeah we do some really good co-treats there, But also collaboration goes kind of beyond within our department, nursing, families. I have a woman who's on a peg right now. And we just did a lot of education with the husband because I was like, just because she's not eating orally consistently doesn't mean that she shouldn't be getting her mouth cleaned regularly. Like, gross stuff, bacteria, plaque, all that yucky goodness builds up. And she's just as at risk for aspirating her saliva with all that gunk in it as she is with any other liquid or solid. So we need to be keeping on top of it with her mouth being clean. And the family was so receptive. It's so nice to work with people who are like, yeah, we're all on board.

Speaker1:
[17:28] I know. And I really feel like sometimes people just, like, you don't know what you don't know. And it's like sometimes it can feel like all the things that we know are just like, well, duh. Like we have gone over this a million times, so you really forget that like, yeah, at least I do sometimes that like people aren't us, like they don't have the same kinds of backgrounds and education that we do. So educating always and often to make sure that everybody is understanding from our perspective and like feels that same sense of urgency that we do about these kind of things.

Speaker0:
[18:06] And to that point, and what you were saying earlier about making sure that oral hygiene is an efficient process for all people involved, not just the patient, but also the nursing staff. When it comes to collaborating, one of the big things I find CNA is reporting when I'm like, hey, this person just obviously hasn't had their mouthwashed. They're like, well, I don't know how to do it because the person doesn't pay attention or the toothpaste is always coming out of their mouth or whatever it is. I'm like, thank you for telling me, you know, because now we can go and we can trial this together and, you know, I can do education, I can do training. But if I don't know why people aren't cleaning my patient's mouth, then I can't help them. So again, always making yourself available to nursing staff for training sessions is a hundred percent a valid thing to do with your time. And I think in a lot of cases, one of the most valuable things to do with your time. I know about you, Emily, at your site, I feel like we have.

Speaker0:
[19:03] A decent amount of full-time staff and a ton of prn and so i think kind of making sure everybody understands someone's oral care routine can be so hard because the patient is getting like, seven different caretakers in a week and that is really disorienting for them nobody seems to know the schedule and so just kind of like every few days tracking someone down being like have you heard the toothbrush lecture have you heard the oral care lecture if not hold your horses because this is going to rock your world. Toothbrushing has got to happen. Let's do it together.

Speaker1:
[19:37] Definitely always trying to like track people down and make sure they understand it. And then also providing that, like you were saying, that open avenue to just come back. Like if you have any questions, like please come and ask. I'm happy to answer any and all questions you have about oral swabs or toothbrushes or why we chose oral swabs versus toothbrushes for this particular patient and how they're even doing in therapy. Like if you want to know like what their goals are for this process, like I'm happy to educate you on like what we're expecting to grow and like how we're moving along in that process.

Speaker0:
[20:20] Yeah. And going back to like the lemon glycerin swab being appropriate sometimes i have this patient who he's just not interested in eating and the wife was asking me what are some options we have i was like well we can do lemon glycerin swab and try and like wake him up because it's like putting a tiny piece of lemon in your mouth she's like oh he's not gonna like that like what does he like lemonade it's like yeah and i was like all right well maybe we'll just do lemonade and then brush afterwards so he doesn't just sitting there yet again with citric acid in his mouth but um you know all of these are good tools and they all have their purpose in our care. We just got to figure out what for.

Speaker1:
[20:57] Yeah. I think too, like a lot of times I'll, when I'm talking about toothbrushes versus the swabs or like oral care in general, I'll find a lot of, a lot of people, especially the patient themselves, they'll come to me and they'll be a dentureless and I'll be like, tell me about your oral care. And they say, what do you mean i have no teeth i'm like yeah no like we still like there's still a process you still have to like if there's food going in your mouth you have to clean it out like you are still accumulating bacteria even the good bacteria accumulates and is becoming bad because there's too much in your mouth you have to clean it out so it's even educating the patients that like no you still have to like use the swab. Like if you're cognizant enough to use the toothbrush with the mouthwash, like that's good. But if you're not and you have no teeth and there's no risk to damaging the teeth and you don't have like a dry mouth, there's not like all those different contradictions. Maybe the lemon glycerin swab is okay, but the swabs with the mouthwash are going to be the best in a lot of those situations. But again, it's person dependent, right? The person sending a pair.

Speaker0:
[22:10] You say you're educating patients a lot with that. I've reeducated a lot of my co-workers on that. They're like, why are we brushing their teeth? They got none. And I'm like, do you have time for the oral care talk? Again, hold your horses. We're about to talk tooth brushing. it's so fun it really is and on the subject of educating your co-workers we made you guys something we did it's our lemon glycerin swab in service and it's kind of a summary of this discussion it talks about lemon glycerin swabs other oral cleansing products toothbrushes potential contraindications and it's just a pretty good simple resource for you to be able to explain this to the folks around you who may not get why we are using different products with different patients.

Speaker1:
[23:02] Or if you're trying to get your facility to order something different. If they only have the lemon glycerin swabs because they heard 20 years ago that these are the best and we're struggling to stock toothbrushes, having this is handy. It has the article attached to it so you can easily be like, hey, I got this from Eve and Emily. Take a look.

Speaker0:
[23:25] Yeah. Awesome, you guys. Well, I feel like this went well. I love talking to you, Emily.

Speaker1:
[23:30] I know. I love you talking. I love you. I love talking to you and I love you.

Speaker0:
[23:35] I love you.

Speaker1:
[23:36] Let's hang out again.

Speaker0:
[23:41] Yes, I really love how you said that. Let's hang out more in recorded format.

Speaker1:
[23:46] It was like a virtual high five. All right, guys. Thank you for listening. Please submit questions.

Speaker0:
[23:52] Comments.

Speaker1:
[23:53] Your funny stories about encouraging people to use lemon gristler and swabs or not swabs or toothbrushes. The things.

Speaker0:
[24:00] We love stories. Good stories. All right.

Speaker1:
[24:04] Have a good one. Bye. Thanks. You've been listening to Speech Talk.

Speaker0:
[24:09] Thank you, everyone, for coming to listen to our research book club. Until next time, keep learning and leading with research.

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Speaker0:
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Speaker1:
[24:40] If you want even more speech talk content, check out our website at speechtalkpod.com, where you can find all of our resources we made for you, copies of articles covered, and Eva's blog following these topics and more.

Speaker0:
[24:52] We're your hosts, Eva Johnson and Emily Brady.

Speaker1:
[24:55] Our editor and engineer is Andrew Sims.

Speaker0:
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