DOI: https://doi.org/10.21203/rs.3.rs-2797013/v1
Objectives
The study aims to determine the level of awareness, knowledge, and practice patterns of Oral Health and Hygiene (OHH) among Speech-Language Pathologists (SLPs) in India.
Materials & Method
A questionnaire was developed to assess the awareness and knowledge regarding OHH among Master's students and professionals practicing speech-language pathology. The sections in the questionnaire included awareness and knowledge of oral health, knowledge of impact of poor oral health, and practices pertaining to assessment and management of oral health. The questionnaire was circulated among 200 SLPs practicing in India.
Results
A total of 162 participants responded to the survey. 93.2% participants were aware of the importance of OHH, however 42.6% participants did not feel confident enough to assess the same. Most (82.7%) agreed that poor OHH could lead to different health complications. 38.8% of the participants responded that they assessed oral health only sometimes and 54.3% reported that they never used standard screening/assessment tools to assess oral health. Only a very small percentage of participants (28.65%) counselled the patients for maintenance of oral hygiene and more than 40% never recommended appropriate OHH practices during management.
Conclusion
The present study is the first of its kind to assess the awareness, knowledge, and practice patterns of OHH among Indian SLPs. The results revealed that though the awareness and knowledge of OHH among the Indian SLPs was good, this did not reflect in their clinical practice
Clinical Relevance:
Collaborative efforts from professional and regulatory bodies and educational institutes are necessary in developing and implementing OHH-related aspects in India. This could potentially improve SLP's knowledge and clinical practices related to oral health and thereby improve patient outcomes.
Oral health is an integral part of overall health and is a marker of health status. It influences several functions central to overall health and quality of life. Poor oral health and untreated oral diseases and conditions can affect the most basic human needs, including the ability to eat and drink, swallow, maintain proper nutrition, smile, and communicate. Poor oral health and hygiene can even expedite serious health conditions such as pneumonia [1, 2], heart diseases, [3] eating disorders, and inadequate nutrition, [4] etc.
Oral health is defined by the World Health Organisation as ‘Being free of chronic mouth and facial pain, oral and throat cancer, oral sores, birth defects such as cleft lip and palate, periodontal disease, tooth decay and tooth loss, and other diseases and disorders that affect the mouth and oral cavity.’ [5] The FDI World Dental Federation defines oral health as the ability to speak, smile, smell, taste, touch, chew, swallow, and confidently convey emotion without pain, discomfort, or disease. [6]
The structures in the oral cavity including teeth, gums, tongue, palate, buccal cavity are vital for speech and swallowing and speech-language pathologists (SLPs) provide services (prevent, assess, diagnose, and treat) to individuals with an array of speech and swallowing disorders across the lifespan. The assessment and management of the body functions and structures used to communicate and swallow are included in the scope of practice of an SLP. [7] As a part of the assessment, the SLPs identify abnormalities in the structure or function of a patient’s oral cavity. Therefore, SLPs are in a unique position to identify the need for oral health care and to provide basic management when appropriate. Part of this scope of practice includes the evaluation and management of oral health to varying degrees. SLPs are included in the professionals who routinely assess oral hygiene and health. [8] Integrating basic oral health care into speech-language pathology practice has the potential to improve oral health equity for several priority populations. [9]
Though Dentists are trained professionals to evaluate the dental and oral health status, when assessing an individual with a communication deficit, they often find it difficult to do the routine oral evaluation. This highlights the importance of add on oral health and hygiene evaluation in the scope of practice of an SLP. The SLPs have extensive knowledge of the normal structures and functions of oral and pharyngeal structures that would facilitate appropriate assessment of oral health. Oral health assessment can help identify any oral health concerns and the management plan may include providing oral health education or referral to an oral health professional. [10]
The assessment of oral health is particularly critical in patients with dysphagia. Patients with oropharyngeal dysphagia who are nil by mouth or on limited oral intake often show poor oral hygiene. [11] The oral cavity serves as a host for multiple microorganisms, including the ones that may be responsible for pneumonia. The thick saliva, in those with xerostomia, serves as a medium for microorganisms to multiply. While performing the swallowing assessment with different boluses, particularly in individuals with pharyngeal dysphagia, these microorganisms can enter the lungs, and if aspirated it can lead to pneumonia.
Oral health is found to be poor in the geriatric population due to several underlying health issues. The prevalence of stroke and other neurological disorders are high in elderly adults. [12] The improvement in oral hygiene can help in the reduction in aspiration pneumonia in individuals with stroke history (Sørensen et al., 2013). Individuals with dementia and cognitive problems also show poor oral health that includes gum problems, unhealthy teeth, a high amount of oral plaques, reduced secretion of saliva, and infections (Delwel et al., 2018).
Individuals of all age groups with a developmental disability also have a high risk of having poor oral health (Scott et al., 1998). Poor oral health and hygiene are common in autism spectrum disorder (Murshid, 2014), intellectual disability (Maltais et al., 2020; Salles et al., 2012), and neurological disabilities including cerebral palsy (Serras&Clav, 2021). Some children with these disorders can have sensory issues and abnormal reflexes which serve as a barrier for adequate oral care. Children with disability need extensive dental care. [13]
There are different tools to assess the oral health such as Oral Health Assessment Guide (OHAG), [14] Subjective Oral Health Status Indicators, [15] Oral health quality of life (OHQoL), [16] Oral health impact profile (OHIP), [17] Oral Health Quality of Life Inventory (OH-QoL), [18] Brief Oral Health Status Examination, [19] The Holistic and Reliable Oral Assessment Tool (THROAT), [20] Revised Oral Assessment Guide (ROHAG), [21] Oral Health Assessment Tool (OHAT), [22] etc. Some of these have been developed for use by non-dental professionals such as nurses, personal care attendants and allied health or medical professionals. [22]
Simpelaere et al. (2016) investigated the feasibility and reliability of the OHAT [22] as used by speech pathologists, to become part of a comprehensive clinical swallowing examination. The findings of this study showed that the OHAT was a feasible and reliable oral health assessment tool that can be used in clinical practice by SLPs to screen oral health in a standardised manner in elderly individuals with dysphagia. [23]
Despite the availability of several tools to assess oral health and despite the fact that oral health assessment and management is a part of scope of practice of SLPs, it is not known whether SLPs, particularly in India are evaluating oral health as a part of routine oral peripheral mechanism examination in all persons with speech and swallowing disorders. To date, there are no studies that have investigated the awareness of SLPs in India about oral health, and integration of oral assessment and management in their clinical practice. Understanding this will help in improving services and practices to persons with speech and swallowing disorders. Keeping this in view, the present study was conceived. The study aims to determine the level of awareness and knowledge of oral health and hygiene amongst the SLPs practicing in India. The study also aims to investigate the practice patterns pertaining to oral health assessment and management among these SLPs.
A descriptive cross-sectional study was conducted among 162 postgraduate (PG) students and professionals from speech-language pathology practicing in India. PG students included those from both first and second-year MSc (SLP). Professionals included those practicing speech-language pathologists with qualification of bachelor degree, master’s degree and doctoral degree. The study included both male and female participants.
A questionnaire was developed to assess the awareness and knowledge regarding oral health and hygiene among students and professionals practicing speech-language pathology. Further the questionnaire also aimed to obtain information on whether the participants were incorporating oral health assessment and management in their clinical practice. To develop the questionnaire, the literature relevant to the present study was reviewed. Approximately 26 questions were collated and compiled under different sections from previous studies and questionnaires developed previously (Simpelaere et al. 2016; Chalmers, King, & Spencer, 2005). The sections in the questionnaire included demographic details, awareness of oral health (1 question), knowledge of oral health (3 questions), knowledge of impact of poor oral health (3 questions), Practices pertaining to assessment of oral health (13 questions), Oral hygiene practices during management (6 questions). The rating scale to obtain the responses to questions under the sections on awareness, education and training, Impact of poor oral health was a binary choice type of Yes/No and a five-point Likert rating scale was designed to obtain the responses to other questions (‘5’ indicated ‘Always’ and ‘1’ indicated ‘Never’). The demographic information was also elicited on a Likert scale. Finally, an awareness leaflet was developed, which was a downloadable file for use by all the participants at the end of the survey. The aim of providing the leaflet to the participants was to create awareness about importance of oral health and hygiene.
To assess the content validity of the questionnaire, the questions were provided to three Speech-Language Pathologists (SLPs) with more than 10 years of clinical experience and they were asked to rate the relevancy and appropriateness of the questions. The questions rated as valid and somewhat valid were considered for study, while the other questions were discarded. The suggestions provided by the SLPs were incorporated. Some of the questions were combined, while others were deleted. The final questionnaire included questions asking respondent demographics, awareness and knowledge of importance of OHH in clinical practice, knowledge of impact of poor oral health, and practices pertaining to assessment and management of oral health. The Scale content validity index(S-CVI) was used (Polit & Beck, 2006) and a calculated score of 0.90 was obtained. The 20-item questionnaire was finalized with the rating scale. A pilot study among five SLPs was carried out. The participants took about 3 to 5 minutes to complete the questionnaire. The final version of the questionnaire was developed as a google form (see Appendix).
Data was collected between the duration 12th December 2021 to 12th January 2022.The developed google form was sent via various social networking platforms like WhatsApp, Messenger and Gmail to 200 practicing clinicians from various institutes, hospitals and clinics in India. The consent of the participants was taken at the first stage of google form. An awareness script was shared with all the participants to create the awareness of importance of oral health and hygiene in the scope of SLP after the participants provided the responses.
The obtained data was descriptively analyzed for continuous variables, while the discrete variables were analyzed based on frequency and percentage. All the analyses were carried out using IBM Statistical Package for Social Sciences (SPSS) version 25.0. (SPSS Inc., Chicago).
The results have been organized into four sections: (a) Respondent demographics, (b) Awareness and knowledge, (c) Knowledge of impact of poor oral health, and (d) Practices pertaining to assessment and management of oral health.
Two hundred participants were selected randomly for the study and among them only 162(81%) responded to the survey. Among the 162 participants, 80 (49.4%) participants had Bachelor’s degree in the field of speech and hearing, while 78 (48.14%) were post graduated in the area of speech language pathology o deglutology. Four (2.4%) had doctoral degree in speech language pathology. Thirty-eight (23.5%) were working in hospitals, 35(21.6%) worked in institutional set up and 36(22.2%) in private clinics and 42(25.9%) were pursuing their postgraduation. Rest of the participants were either working in schools (4.3%, n = 7) or were currently unemployed (1.8%, n = 3). Most survey participants {(64.8% (105)} had one to five years of clinical experience, while 27.8% (45) had less than one year of experience. Only 12(7.4%) respondents reported to have more than five years of experience in the field.
When asked about experience in dealing with clients with dysphagia, 22.8% of them reported to have five or lesser years of experience, half of the participants (50.7%) reported they had less than one year of experience and 25.3% never had any experience. Only 1.2% reported to have experience of more than six years. Almost two-third (57.4%) reported that clients with dysphagia was a part of their caseload sometimes, while 26.5% reported to have never encountered clients with dysphagia. The 4.9%, 3.1% and 8% of the participants reported they always, most of the time and half of the times see a dysphagia client respectively.
A significant correlation was found using the Chi square test between number of clients with dysphagia seen and awareness of importance of including OHH in OPME (X2(4) = 17.797, p = 0.001). The case load did not show any correlation with other responses obtained.
93.2% (n = 151) participants were aware of the importance of oral health and hygiene in clinical practice, while the remaining 6.8% (n = 11) were not aware. Only 57.4% (n = 93) participants felt competent to assess oral health and hygiene and 42.6% (n = 69) participants did not feel confident enough to assess oral health and hygiene. Table 1 shows the number of responses on questions regarding the awareness and competency of practicing OHH. Almost half of the participants (47.5%; n = 77) reported that they were never taught regarding the oral health and hygiene during their clinical training period as a part of their curriculum. 62.3% (n = 101) participants tried to search for the information regarding oral health and hygiene from additional resources such as websites/books to improve their clinical competency, while remaining 37.7% (n = 61) never explored this area.
| Education | No of participants competent in OHH | No of participants aware of importance of OHH | |||
|---|---|---|---|---|---|
| BASLP | 42 | 74 | |||
| Post graduates | 49 | 73 | |||
| Doctorate (PhD) | 2 | 4 | |||
| Total | 93 | 151 | |||
| OHH: Oral Health and Hygiene; SLP: Speech-Language Pathology; BASLP: Bachelor of Audiology and Speech Language Pathology | |||||
75.9% (n = 123) participants believed that poor oral health and hygiene can lead to conditions like stroke, dementia or oral cancer, while remaining 24.1% (n = 39) reported against it. Similarly, 89.5% (n = 145) believed that poor oral health and hygiene could lead to aspiration pneumonia, particularly in patients with dysphagia, while 10.5% (n = 17) participants responded against this. Along with this, 78.4% (n = 127) responders also believed that speech intelligibility is highly affected due to poor oral health and hygiene, while 21.6% (n = 35) responded against this claim.
The information to the questions under this section was obtained using the 5-point Likert scale. The majority of the participants responded that they assessed oral health as a part of the oral peripheral mechanism examination (OPME) (38.8%, n = 63), referred patients for dental consultation (54.9%, n = 89), and counselled patients regarding maintenance of OHH (29.0%, n = 47) only sometimes. However, a maximum number of participants reported that they never used any standard screening/assessment tools to assess oral health (54.3%, n = 88), never assessed the color, thickness, and amount of saliva during oral health assessment (44.4%, n = 72), never assessed halitosis (48.1%, n = 78), never assessed the frequency of brushing teeth (35.1% (n = 57), never assessed the cleanliness of tongue (33.3%, n = 54), never enquired whether they had gone for a prior dental consultation (41.9%, n = 68), never cleaned mouth before performing FEES or VFSS (37.0%, n = 60), never recommended appropriate positioning during tooth brushing (46.2%, n = 75), never recommended oral hygiene practices in those without teeth/ those using dentures (40.7%, n = 66) and never recommended alternatives such as an electronic toothbrush or Interdental brush/ dental floss for those with difficulty in moving hands and arms/ locked jaw/ clenching (44.4%, n = 72). The number of responses obtained across the Likert scale in the section on practices pertaining to assessment and management of oral health is depicted in Table 2.
The Chi square analysis revealed that the educational qualification and the response obtained for the questions regarding the assessment of color, thickness and amount of saliva (X2(4) = 9.57, p = 0.04), halitosis (X2(4) = 16.26, p = 0.003), frequency of brushing (X2(4) = 15.14, p = 0.004), and oral hygiene practices in those without teeth/ those using dentures (X2(4) = 10.06, p = 0.039) had a significant correlation, while the rest of the responses did not have any correlation with educational qualification. There was no significant correlation found between professional experience as an SLP and in dealing with clients with dysphagia with all the responses obtained in the section on practices pertaining to assessment and management of oral health. Further, no significant correlation was found between number of clients with dysphagia seen and other responses obtained in the section on practices pertaining to assessment and management of oral health.
| Frequency of Responses | |||||
|---|---|---|---|---|---|
| Questions | Always | Most of the time | Half the time | Sometimes | Never |
| Oral health/ hygiene as a part of OPME | 34 | 28 | 17 | 63 | 20 |
| Use of oral health/hygiene screening/assessment tools | 10 | 8 | 11 | 45 | 88 |
| Assess the color, thickness and amount of saliva during oral health assessment | 15 | 20 | 5 | 50 | 72 |
| Assess halitosis (bad breath) | 16 | 15 | 5 | 48 | 78 |
| Frequency of brushing teeth | 20 | 18 | 16 | 51 | 57 |
| Cleanliness of the tongue | 21 | 24 | 14 | 49 | 54 |
| Prior dental consultation | 13 | 11 | 12 | 58 | 68 |
| Refer your patients to a dentist | 4 | 13 | 9 | 89 | 47 |
| Clean the mouth before performing a FEES or videofluroscopic examination | 27 | 22 | 14 | 39 | 60 |
| Counsel patients on the maintenance of oral hygiene | 46 | 32 | 17 | 47 | 20 |
| Proper positioning during tooth brushing | 17 | 19 | 15 | 36 | 75 |
| Oral hygiene practices in those without teeth/ those using dentures | 16 | 22 | 12 | 46 | 66 |
| Recommended alternatives such as an electronic toothbrush or Interdental brush/ dental floss for those having difficulty in moving hands and arms/ locked jaw/ clenching to clean the area in between teeth | 15 | 12 | 15 | 48 | 72 |
The study was conducted to investigate the awareness and knowledge of oral health and hygiene among the SLPs practicing in India. The study also aimed to investigate the practice patterns pertaining to oral health assessment and management among these SLPs. To our knowledge, this is the first study to report awareness and knowledge of oral health and hygiene among the SLPs within the context of India. Overall, it was seen that there was a variability in the data, which could be attributed to differences in training and SLPs knowledge about oral health. The results presented here evaluated this variability and the key findings are briefly discussed in the context of the current literature.
The results revealed that a vast majority of the participants (93.2%) were aware of the importance of oral health and hygiene in clinical practice. However, 42.6% (55% of them were BASLP graduates, 42% post graduates, 2.9% doctorate holders) participants did not feel confident enough to assess oral health and hygiene, probably because this aspect was never covered during their clinical training period as a part of their curriculum as indicated by the participants. The lack of confidence indicates that there is a need to include the oral health and hygiene issues, atleast in the dysphagia course that they study during their Master’s program. This is a significant lapse in the curriculum, which needs to be updated. However, 62.3% did make attempts to gain more information regarding oral health and hygiene from additional resources, which indicated that they were catering to clients with oral health issues and were trying to make a difference in their lives by looking for more information through various sources. This again supports the fact that the course curriculum should cover aspects of oral health.
A vast majority (75.9% and 89.5%) of the participants believed that poor oral health and hygiene can lead to conditions like stroke, dementia or oral cancer and aspiration pneumonia in dysphagia patients respectively. 78.4% of the participants also believed that speech intelligibility is highly affected due to poor oral health and hygiene. These results indicated that SLPs were very much aware and knew the consequences of poor oral health.
With respect to incorporating practices pertaining to oral health, 38.8% of the participants responded that they assessed oral health only sometimes as a part of the oral peripheral mechanism examination (OPME) and 54.3%, reported that they never used any standard screening/assessment tools to assess oral health. This indicated that very few SLPs incorporate formal oral health assessment as a part of their assessment protocol. According to Yoon and Steele, (2012), oral health assessment is included under the scope of practice of SLPs. [8] Integrating basic oral health care into speech-language pathology practice has the potential to improve oral health equity for several priority populations. [9]. However, in the Indian scenario, most SLPs are not assessing the oral health. This is further supported by the fact that 44.4% never assessed the color, thickness and amount of saliva, 48.1% never assessed halitosis, 35.1% never assessed the frequency of brushing teeth, 33.3% never assessed the cleanliness of tongue, and 41.9% never enquired whether they had gone for a prior dental consultation. This data indicated that there is a dire need to train the Indian SLPs in this area so that they could effectively assess oral health.
The assessment of oral health is particularly critical in patients with dysphagia, as those who are nil by mouth often show poor oral hygiene. [11] Typically, before performing instrumental assessment with different bolus consistencies, it is essential to clean the oral cavity. However, 37.0% of the SLPs never cleaned the mouth of the clients with dysphagia before performing FEES or VFSS. This indicates their poor clinical skills. Though majority knew the consequences of poor oral health, they did not take necessary precautions while performing standard procedures.
According to Goodell et al. (2019), though Dentists are trained professionals to evaluate the dental and oral health status, when assessing an individual with a communication deficit, they often find it difficult to do the routine oral evaluation. [10] However, the Indian SLPs do not realize this and 54.9% of them reported that they would refer the clients to the dentists. This indicated that the Indian SLPs are not aware of their role in oral health assessment and consider it to be predominantly to be the domain of dentists. Since the SLPs learn extensively about the structures and functions of oral and pharyngeal structures, it would be appropriate for them to learn about the assessment of oral health.
Counselling is one of the important duties of the SLPs. Informational counseling or client and family/caregiver education, involves discussing with individuals and their families/caregivers the nature of a disorder or situation, intervention considerations and techniques, prognosis, and material and community resources. [24] The results of the present study also revealed that only a very small percentage of participants (28.65%) counselled the patients for maintenance of oral hygiene. 46.2% never recommended appropriate positioning during tooth brushing, 40.7% never recommended oral hygiene practices in those without teeth/ those using dentures and 44.4% never recommended alternatives such as an electronic toothbrush or Interdental brush/ dental floss for those with difficulty in moving hands and arms/ locked jaw/ clenching. All these are important considerations which the SLPs need to inform the clients during the management; however, the Indian SLPs do not practice these. The scope of SLP includes oral care management, particularly in persons with dysphagia. [23] The care and maintenance of oral health and the possible health risks for poor oral health and hygiene in a person with disability should be educated among SLPs. The clinical and academic curriculum should focus on the topics pertaining to oral health assessment and management in order to enrich the knowledge of SLPs, which will improve the quality-of-service delivery of the SLPs. The practicing SLPs in India should elaborate and update their knowledge in oral health. The national level continuing education programs may also help to improve the knowledge among the practicing SLPs.
The current study aimed to identify the awareness and knowledge of SLPs on Oral health and hygiene and the inclusion of the same in their routine clinical practice. The result revealed the though the awareness and knowledge of oral health and hygiene among the Indian SLPs was good, the same did not reflect in their clinical skills. This indicates the need to inform SLPs about their scope of practice in the assessment and management of oral health. This can be taken up by by governing bodies such as the Indian Speech and Hearing Association and the Rehabilitation Council of India (RCI). This could also be due to the lack of inclusion about oral health in the course curriculum and in the clinical curriculum, which could also be taken up by RCI. Professional awareness programs and conferences should also focus on the area of oral health that can enhance the knowledge and the quality of service of SLPs. Addressing these will ultimately lead to enhanced service provision for patients with dysphagia and other communication disorders in India.
Though the responses were obtained from a good number of participants, there are a few limitations which need to be acknowledged. The possibility of the limited introspective ability of the respondees in response to the self-reported questionnaire is a limitation of the study. The questionnaire was based solely on the clinician report and perceptions, and thus may not be a true reflection of actual practice employed by the SLPs in India. Hence future studies could include direct observational methods to examine the oral health assessment and management practice patterns and the factors that influence them. The reliability of the response also cannot be ascertained. The broad area of interest of each SLP could also have influenced the responses obtained. The experience of SLPs dealing with dysphagia and other communication disorders is an influencing factor. The survey participants also represented a younger pool with limited clinical experience. It is possible that these practices are different for more experienced SLPs.
Despite these limitations, the results do open some opportunities for inclusion of information about oral health assessment and management in the academic and clinical training programs offered in India. Collaborative efforts from professional and regulatory bodies and educational institutes are necessary in developing and implementing oral health related aspects in India. This could potentially improve SLP knowledge and clinical practices related to oral health and thereby improve patient outcomes.
Oral health and hygiene
Speech-Language Pathologists
Oral Peripheral Mechanism Examination
Oral Health Assessment Tool
The manuscript has been read and approved by all the authors, the requirements for authorship as stated earlier in this document have been met, and each author believes that the manuscript represents honest work of the investigators.
Acknowledgement:
We sincerely thank the Director, All India Institute of Speech and Hearing, Mysuru, and Dr. M.S. Vasantha Lakshmi, biostatistician for their support in conducting this study.
Consent for publication: Not applicable
Previous presentations made:
The current study was presented in International Audiology Conference 2022 conducted by International Association of Communication Sciences and Disorders.
Source of funding: There is no funding to disclose.
Conflict of Interest: There is no conflict of interest to disclose
Author Contributions
Authors Syam Krishna V, and Biraj Bhattarai have significantly contributed in the conceptualization, planning, execution, analysis and report writing of the current study. Swapna N was involved in the conceptualization, planning and writing the manuscript.
Informed Consent: The consent form was given along with the online questionnaire that marked as “yes/no” by the participants.
“Your participation in this survey is voluntary. You may refuse to take part in the research or exit the survey at any time without penalty. No one will be able to identify you or your answers, and no one will know whether or not you participated in the study.”
Ethical Approval: The study is approved by the ethical committee of All India Institute of Speech and Hearing, Mysore in accordance with the ethical guidelines of bio-behavioural research involving human subjects.