Bulbar syndrome treatment with folk remedies. Bulbar nerves (IX-XII). Characteristic manifestations of the bulbar syndrome

Gradually developing dysfunction of the bulbar group of the caudal cranial nerves, due to damage to their nuclei and / or roots. A triad of symptoms is characteristic: dysphagia, dysarthria, dysphonia. The diagnosis is established on the basis of examination of the patient. Additional examinations (analysis of cerebrospinal fluid, CT, MRI) are carried out to determine the underlying pathology that caused bulbar palsy. Treatment is prescribed in accordance with the causative disease and the symptoms present. Urgent measures may be required: resuscitation, mechanical ventilation, the fight against heart failure and vascular disorders.

General information

Bulbar palsy occurs when the nuclei and / or roots of the bulbar group of cranial nerves located in the medulla oblongata are damaged. Bulbar nerves include glossopharyngeal (IX pair), vagus (X pair) and hypoglossal (XII pair) nerves. The glossopharyngeal nerve innervates the muscles of the pharynx and provides its sensitivity, is responsible for the taste sensations of the posterior 1/3 of the tongue, and provides parasympathetic innervation to the parotid gland. The vagus nerve innervates the muscles of the pharynx, soft palate, larynx, upper digestive tract and respiratory tract; gives parasympathetic innervation of internal organs (bronchi, heart, gastrointestinal tract). The hypoglossal nerve provides innervation to the muscles of the tongue.

The cause of bulbar paralysis may be chronic cerebral ischemia, which developed as a result of atherosclerosis or chronic vascular spasm in hypertension. Rare factors causing damage to the bulbar group of cranial nerves include craniovertebral anomalies (primarily Chiari anomaly) and severe polyneuropathies (Guillain-Barré syndrome).

Symptoms of progressive bulbar palsy

The clinical manifestations of bulbar palsy are based on peripheral paresis of the muscles of the pharynx, larynx and tongue, which results in impaired swallowing and speech. The basic clinical symptom complex is a triad of signs: swallowing disorder (dysphagia), impaired articulation (dysarthria) and sonority of speech (dysphonia). Swallowing disorders begin with difficulty in taking liquids. Due to paresis of the soft palate, fluid from the oral cavity enters the nose. Then, with a decrease in the pharyngeal reflex, swallowing and solid food disorders develop. The restriction of the mobility of the tongue leads to difficulty in chewing food and moving the food bolus in the mouth. Bulbar dysarthria is characterized by blurred speech, lack of clarity in the pronunciation of sounds, due to which the patient's speech becomes incomprehensible to others. Dysphonia manifests itself as a hoarse voice. Nazolalia (nasal) is noted.

The patient's appearance is characteristic: the face is hypomimic, the mouth is open, there is salivation, difficulty in chewing and swallowing food, and its loss from the mouth. In connection with the defeat of the vagus nerve and the violation of the parasympathetic innervation of the somatic organs, disorders of the respiratory function, heart rhythm and vascular tone occur. These are the most dangerous manifestations of bulbar paralysis, since often progressive respiratory or heart failure causes the death of patients.

When examining the oral cavity, atrophic changes in the tongue, its folding and unevenness are noted, fascicular contractions of the muscles of the tongue can be observed. The pharyngeal and palatine reflexes are sharply reduced or not evoked. Unilateral progressive bulbar palsy is accompanied by drooping of half of the soft palate and deviation of its uvula to the healthy side, atrophic changes in 1/2 of the tongue, deviation of the tongue towards the lesion when it protrudes. With bilateral bulbar paralysis, glossoplegia is observed - complete immobility of the tongue.

Diagnostics

Diagnosis of bulbar paralysis by a neurologist allows a thorough study of the patient's neurological status. The study of the function of the bulbar nerves includes an assessment of the speed and intelligibility of speech, the timbre of the voice, the volume of salivation; examination of the tongue for the presence of atrophies and fasciculations, assessment of its mobility; examining the soft palate and checking the pharyngeal reflex. It is important to determine the respiratory rate and heart rate, the study of the pulse to detect arrhythmia. Laryngoscopy allows you to determine the absence of complete closure of the vocal cords.

In the course of diagnosis, progressive bulbar palsy must be distinguished from pseudobulbar palsy. The latter occurs with a supranuclear lesion of the cortico-bulbar tracts connecting the nuclei of the medulla oblongata with the cerebral cortex. Pseudobulbar paralysis is manifested by central paresis of the muscles of the larynx, pharynx and tongue with hyperreflexia characteristic of all central paresis (increased pharyngeal and palatine reflexes) and increased muscle tone. Clinically differs from bulbar paralysis by the absence of atrophic changes in the tongue and the presence of reflexes of oral automatism. Often accompanied by violent laughter resulting from spasmodic contraction of facial muscles.

In addition to pseudobulbar paralysis, progressive bulbar paralysis requires differentiation from psychogenic dysphagia and dysphonia, various diseases with a primary muscular lesion that causes myopathic paresis of the larynx and pharynx (myasthenia gravis, Rossolimo-Steinert-Kurshman myotonia, paroxysmal myoplegia, oculopharyngeal myopathy). It is also necessary to diagnose the underlying disease that led to the development of the bulbar syndrome. For this purpose, a study of cerebrospinal fluid, CT and MRI of the brain is carried out. Tomographic studies make it possible to visualize brain tumors, demyelination zones, cerebral cysts, intracerebral hematomas, cerebral edema, displacement of cerebral structures in dislocation syndrome. CT or radiography of the craniovertebral junction can reveal abnormalities or post-traumatic changes in this area.

Treatment of progressive bulbar palsy

Therapeutic tactics for bulbar palsy is built taking into account the underlying disease and leading symptoms. In case of infectious pathology, etiotropic therapy is carried out, in case of cerebral edema, decongestant diuretics are prescribed, in case of tumor processes, together with a neurosurgeon, the issue of removing the tumor or performing a bypass operation to prevent dislocation syndrome is decided.

Unfortunately, many diseases in which bulbar syndrome occurs are a progressive degenerative process occurring in cerebral tissues and have no effective specific treatment. In such cases, symptomatic therapy is carried out, designed to support the vital functions of the body. So, in case of severe respiratory disorders, tracheal intubation is performed with the patient connected to a ventilator, in case of severe dysphagia, tube nutrition is provided, and vascular disorders are corrected with the help of vasoactive drugs and infusion therapy. To reduce dysphagia, neostigmine, ATP, vitamins gr. B, glutamic acid; with hypersalivation - atropine.

Forecast

Progressive bulbar palsy has a highly variable prognosis. On the one hand, patients may die from heart failure or respiratory failure. On the other hand, with successful treatment of the underlying disease (for example, encephalitis), in most cases, patients recover with full recovery of swallowing and speech function. Due to the lack of effective pathogenetic therapy, bulbar palsy has an unfavorable prognosis associated with progressive degenerative damage to the central nervous system (with multiple sclerosis, ALS, etc.).

The defeat of the IX, X and XII nerves of the skull or their nuclei causes bulbar syndrome.

At the same time, it is observed paralysis of the palatine and lingual muscles, vocal cords, epiglottis, impaired sensitivity of the mucous membrane of the nasopharynx, larynx, trachea with certain manifestations: problems with swallowing, food entering the respiratory system, speech deviations, taste disturbances on the back of the tongue, autonomic disorders.

Pseudobulbar syndrome appears as a result of bilateral damage to the cortical fibers. With a unilateral dysfunction of the nerves, except for the XII pair, they are not violated, because. their nuclei have bilateral innervation.

Causes of syndromes

The main causes of bulbar syndrome include various diseases.

At the beginning of the disorder, there is difficulty in swallowing liquid food. However, with the development of the disorder, along with the weakness of the tongue, weakness of the muscles of the face and chewing muscles appears, and the tongue becomes motionless.

Men are more likely to suffer from dystrophic myotonia. The disease begins at the age of 16.

bulbar syndrome causes dysphagia, nasal tone of voice, choking, and in some cases - respiratory failure; bouts of muscle weakness.

The development of the disorder is provoked by increased salt intake, carbohydrate-rich foods, stress and negative emotions, debilitating physical activity. In pseudobulbar syndrome, two parts of the medulla oblongata are involved.

Psychogenic disorders can be combined with psychotic disorders, conversion disorders.

This disorder is manifested by central paralysis of swallowing, changes in phonation and articulation of speech.

Disorders appear when diseases:

• Alzheimer's disease;
• amavrotic idiocy;
• amyotrophy;
• Kennedy disease;
• damage to the arteries of the brain;
• botulism;
• bulbar paralysis;
• thrombosis of venous sinuses;
• glycogenosis;
• Gaucher disease;
• diffuse sclerosis;
• myasthenia gravis;
• olivopontocerebellar degeneration;
• brain formation;
• polyradiculoneuropathy;
• polyneuropathy;
• myelinolysis;
• syringobulbia;
• myopathy;
• encephalomyelitis;
• Binswanger's encephalopathy.

Clinical picture

Bulbar and pseudobulbar syndromes have largely similar symptoms and signs, since the common thing for these disorders is the effect on one muscle.

But if pseudobulbar deviation appears in violation of the central motor neuron, then bulbar - in violation of the peripheral neuron. That is, pseudobulbar palsy is central, and bulbar palsy is peripheral.

Accordingly, in the clinic of pseudobulbar disorders, the main thing is an increase in muscle tone, the occurrence of unhealthy reflexes and the absence of muscle atrophy.

In the clinic of the bulbar, the main is muscle weakness, the appearance of muscle twitching, the death of muscle tissue, and the absence of reflexes.

Manifestations of both types of lesions occur simultaneously with.

Diagnostic methods

After visiting a specialist to identify the disorder, it is usually necessary to go through some examinations:

• Analysis of urine;
• EMG of the tongue, limbs and neck;
• blood tests;
• CT or ;
• esophagoscopy;
• examination by an ophthalmologist;
• clinical and EMG tests for myasthenia gravis;
• research of liquor;

Bulbar and pseudobulbar syndrome in children

For children's practice, the pseudobulbar form is the most significant.

Pseudobulbar form

Children with pseudobulbar disorder often stay in auxiliary schools, because its outward manifestations are so severe that they force doctors and teachers to send children without problems with intellect only because of speech to special schools, and sometimes even to social welfare institutions.

From a neurological point of view, this form has a complex picture: together with the central paralysis of the muscles of the speech apparatus, the baby has changes in muscle tone, hyperkinesis, and other movement disorders.

The complexity of the disease determines the features of its manifestations.

This form of deviation in children is a standard manifestation of cerebral palsy, which often appears before 2 years of age due to brain diseases. Often, cerebral palsy is a consequence of trauma during childbirth.

Motility disorders in these babies are widespread.

Often affected the upper part of the face, because of which it is motionless, there is a general awkwardness, clumsiness. Parents notice that the baby cannot serve himself, does not actively move.

All non-speech functions involving the tongue, lips and other parts of the speech apparatus are also impaired: the child hardly chews food, swallows, cannot swallow and retain saliva.

bulbar syndrome

Bulbar dysarthria occurs when inflammation or formation of the medulla oblongata.

At the same time, the nuclei of the motor cranial nerves located there die.

Paresis is characteristic muscles of the pharynx, tongue, soft palate.

In a baby with this disorder, swallowing food is disturbed, chewing is difficult.

In children with this form of deviation, the muscles of the tongue and pharynx die off. Speech is slurred and slow. The face of a baby with bulbar dysarthria is motionless.

Treatment of the disease

In some cases, urgent care is needed to save a life with bulbar syndrome.

The main purpose of this assistance is neutralization of the threat to the life of the patient before being taken to a medical facility, which will then determine and prescribe treatment.

The doctor, in accordance with the symptoms and nature of the disorder, can assume the outcome of the disease, as well as the effectiveness of the prescribed treatment for bulbar syndrome, which is carried out in stages, and exactly:

• resuscitation, support of body functions that were impaired due to the disorder - restoration of breathing, triggering of the swallowing reflex, reduction of salivation;
• this is followed by the treatment of manifestations, aimed at alleviating the patient;
• treatment of the disease due to which the syndrome occurred;
• feeding of patients is made by means of a food probe.

In the photo, special gymnastics for bulbar syndrome

A good result is achieved in the treatment of pseudobulbar syndrome with the use of stem cells.

Their introduction to a patient with pseudobulbar disorder leads to the fact that they replace the functionally affected cells. As a result, a person begins to live normally.

Quite important in pseudobulbar and bulbar syndromes take good care of your mouth, as well as, if necessary, observe the patient while eating, so as not to suffocate.

Prognosis and complications

Depending on the nature of the disorder, the clinical signs that provoked the syndrome, the doctor assumes the outcome and effectiveness of the treatment, which is usually aimed at eliminating the causes of the main deviation.

It is also necessary to support and restore disturbed body functions: breathing, swallowing, salivation, etc.

Thanks to the use of proven drugs, it is often possible to achieve an improvement in the patient's condition, but it is very rare to achieve a complete cure.

Prevention

The prevention of this violation consists in the prevention of serious diseases that can provoke paralysis.

Prevention of pseudobulbar syndrome includes definition and treatment atherosclerosis of cerebral vessels, prevention of strokes.

must be adhered to mode of work and rest, limit the caloric content of food, reduce the consumption of animal proteins and products with cholesterol. There is no specific prophylaxis.

It is very important to immediately contact a specialist who will not only select the right treatment, but also help reduce the manifestations of the disorder in order to improve the quality of life of the patient.

Video: Bulbar syndrome

Clinical variants of bulbar syndrome. Methods of treatment - therapeutic exercises and electrical stimulation for the syndrome.

Bulbar paralysis is a syndrome of unilateral or bilateral lesions of 9, 10, 12 pairs of cranial nerves (glossopharyngeal, vagus, hypoglossal), the causes lie in the lesion of the medulla oblongata, sometimes they cannot be established.

The syndrome is accompanied by a decrease in the motor activity of muscle groups.

Concomitant diseases

Bulbar paralysis is observed both in complex and autonomously in such diseases as:

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For the correct diagnosis of Guillain-Barré syndrome, it is necessary to pay attention to the clinical picture of the disease, which is characterized by:

1. nonspecific infection preceding the first signs of the disease;
2. lack of clear age limits - can develop at any age;
3. the beginning of development is evidenced by paresthesia and pain;
4. first, paresis develops in the proximal sections, then rapidly and symmetrically spread further;
5. deep reflexes in the affected muscle groups disappear;
6. motive disturbances are more expressed, than sensitive;
7. distribution of abnormalities to the cranial nerves;
8. an increase in protein concentration in the cerebrospinal fluid with a normal increase in the number of cells;
9. gradual recovery of motor functions;
10. no recurrence of the disease.

Symptoms

• Violation of the swallowing function due to a disorder in the work of the muscles that regulate this process, which leads to difficulty swallowing. Disorders of the muscles of the tongue, soft palate, larynx, pharynx, epiglottis are revealed. Added to this is aphagia - the inability to swallow. In this case, liquids enter the nasal cavity, and solid food enters the larynx. The condition is accompanied by a strong secretion of saliva. Food can enter the windpipe or lungs, which can lead to aspiration pneumonia and be fatal.
• Speech disorder up to the loss of the ability to speak. Speech becomes inaccessible to perception, the voice may disappear.
• Rapid onset of fatigue when talking.

There is a violation of pronunciation - dysarthria, the development of complete muscle paralysis is possible. The patient hears and understands what others are saying, but cannot respond.

Bulbar syndrome affects the state of other organs and systems, especially the respiratory and cardiovascular, due to their close location in relation to the destroyed areas of the nerves.

Treatment

The effectiveness of the treatment of manifestations of the bulbar syndrome depends on the success of the treatment of the underlying disease that caused it.

The essence of therapy is to restore impaired functions and maintain the overall viability of the body. For this purpose, it is recommended to take vitamins, ATP (adenosine triphosphate - a compound involved in the metabolism of energy and substances in the body), Prozerin.

Artificial lung ventilation is used to normalize respiratory functions. To reduce the secretion of saliva, Atropine is taken, since in patients the volume of secretions of the salivary glands can reach up to 1 liter. However, all therapeutic measures may not lead to a complete recovery, but only improve the general condition.

What is the difference between bulbar palsy and pseudobulbar palsy?

Pseudobulbar palsy is a centralized paresis of muscles, the functioning of which is regulated by the work of bulbar nerve fibers.

If with bulbar palsy there is a unilateral or bilateral nerve lesion, then with pseudobulbar palsy there is a complete destruction of the nuclear pathways from the cortical centers to the fiber nuclei.

It is accompanied by dysfunction of the muscles of the pharynx, vocal cords, articulation disorder.

The main signs are similar to the manifestations of bulbar palsy:

• dysphagia;
• dysphonia or aphonia;
• dysarthyria.

The main difference is the absence of atrophic processes of the tongue muscles and defibrillary reflexes.

With pseudobulbar syndrome, there is a uniform paresis of the facial muscles, which manifests itself in a violation of their movements. This is combined with an increase in the reflexes of the lower jaw and chin.

The muscles of the lips, pharynx, soft palate do not atrophy, in contrast to the condition with bulbar syndrome.

The changes do not affect the work of the respiratory and cardiovascular systems, which is due to a slightly different localization of pathological processes. Violations of vital functions do not occur, which is also a difference from the symptoms of bulbar paralysis.

reflexes

The hallmark of bulbar syndrome is uncontrollable laughter or crying when something is held over bare teeth (such as a sheet of paper).

Pseudobulbar syndrome is characterized by manifestations of the following reflexes:

In addition to these symptoms, there are a number of others associated with multiple lesions of brain regions. There is a decrease in motor activity, memory impairment, concentration of attention, loss of intelligence. Due to the resulting paresis, the face becomes motionless.

Accompanying illnesses

Pseudobulbar paralysis develops against the background of:

• significant circulatory disorders in both hemispheres of the brain;
• atherosclerosis of cerebral vessels;
• motor neuron disease;
• tumors of some parts of the brain;

In treatment, Prozerin is often prescribed to relieve symptoms. Be sure to use drugs whose action is aimed at improving blood clotting and accelerating metabolic processes.

Bulbar syndrome in medicine is the so-called peripheral paralysis of the muscles of the soft palate, lips, tongue, vocal cords, which, in turn, occurs due to damage to 9, 10 and 12 pairs of the cranial nerves themselves or their nuclei. At the moment, experts identify a great many reasons leading to this kind of ailment. These are inflammatory processes in the brain, and the appearance of neoplasms in it, and a violation of trophism. However, on the other hand, one should also distinguish between the concepts of bulbar and pseudobulbar syndrome.

Primary symptoms of the disease

When a disease such as bulbar syndrome occurs, patients usually complain of the following symptoms:

• getting liquid food into the nose;
• dysphonia;
• disturbances in the respiratory processes (arrhythmia, Cheyne-Stokes breathing);
• a drop in cardiac activity;
• almost complete disappearance of the mandibular reflex;
• regular muscle twitches of the tongue.

Diagnosis

Specialist forecasts and possible complications

After diagnosing, the specialist is most often able to give an accurate prognosis of the course of the disease. So, with advanced stages and damage to the medulla oblongata, the patient is likely to die. The thing is that in this kind of situation there are violations of the primary functions of the respiratory processes, as well as the entire cardiovascular activity of the patient's body as a whole.

bulbar syndrome. Treatment

Therapy, according to modern medicine, should first of all be aimed at treating the underlying disease and at the same time compensating for the already lost vital primary functions of the body. So, to improve swallowing, glutamic acid, prozerin, various vitamins, nootropic drugs and ATP are prescribed. In the case of increased salivation, atropine is used. Absolutely all patients are fed through a special probe. At more advanced stages of the disease, when there are violations of the respiratory process, artificial ventilation is recommended. As for the issue of resuscitation, they, in turn, are carried out exclusively according to indications.

Conclusion

In conclusion, we note that over the past few years, modern medicine has literally stepped a hundred steps forward in this matter. Today, the number of deaths with this diagnosis has significantly decreased.

Bulbar syndrome refers to the pathology of the cranial nerves, when not a single nerve is affected, but a whole group: glossopharyngeal, vagus and hypoglossal, the nuclei of which are located in the medulla oblongata.

Symptoms and causes of bulbar syndrome

Bulbar syndrome (otherwise - bulbar palsy) can be one- or two-sided. Against the background of pathology, swallowing disorders most often occur. This leads to the fact that it becomes difficult or impossible (aphagia). Also, usually against the background of the syndrome, articulation disorders of speech and voice occur - it acquires a nasal and hoarse hue.

Disorders of the autonomic system may also develop, usually manifested as a violation of cardiac activity and respiration.

The most common symptoms of bulbar syndrome are:

• Lack of facial expressions, inability to independently chew, swallow, close your mouth;
• Entry of liquid food into the nasopharynx;
• Hanging of the soft palate and deviation of the tongue in the direction opposite to the paralysis lesion;
• Lack of palatine and pharyngeal reflexes;
• Slurred, nasal speech;
• Phonation disorders;
• Cardiovascular disorders;
• Arrhythmia.

The main causes of bulbar syndrome, doctors include various diseases:

• Myopathy - oculopharyngeal, Kearns-Sayre syndrome. A feature of the hereditary disease of oculopharyngeal myopathy, as one of the causes of bulbar syndrome, is a late onset (most often after 45 years), as well as muscle weakness, limited to the muscles of the face and bulbar muscles. The main maladaptive syndrome is;
• Motor neuron diseases - Fazio-Londe spinal amyotrophy, amyotrophic lateral sclerosis, Kennedy bulbospinal amyotrophy. At the beginning of the disease, there is difficulty in swallowing more liquid food than solid food. However, with the progression of the disease, along with the weakness of the tongue, weakness of the facial and masticatory muscles develops, and the tongue in the oral cavity becomes atrophic and immobile. There is weakness of the respiratory muscles and constant salivation;
• Dystrophic myotonia, which more often affects men. The disease begins at the age of 16-20. Bulbar syndrome leads to dysphagia, nasal tone of voice, choking, and in some cases - to respiratory disorders;
• Paroxysmal myoplegia, manifested by partial or generalized attacks of muscle weakness, which can last from half an hour to several days. Provoke the development of the disease increased consumption of salt, rich in carbohydrates rich food, stress and negative emotions, increased physical activity. Respiratory muscles are rarely involved;
• Myasthenia, the main clinical manifestation of which is excessive muscle fatigue. Its first symptoms are usually dysfunctions of the oculomotor muscles and muscles of the facial muscles and limbs. Often, bulbar syndrome affects the masticatory muscles, as well as the muscles of the larynx, pharynx, and tongue;
• Polyneuropathy, in which bulbar paralysis is observed against the background of tetraplegia or tetraparesis with quite characteristic disorders that make it easier to diagnose and treat bulbar syndrome;
• , which is recognized by general infectious symptoms, the rapid development of paralysis (usually in the first 5 days of illness) with a significantly greater lesion of the proximal than the distal;
• Processes occurring in the posterior cranial fossa, brain stem and cranio-spinal region, including tumor, vascular, granulomatous diseases and bone anomalies. Usually these processes involve the two halves of the medulla oblongata;
• Psychogenic dysphonia and dysphagia, which can accompany both psychotic disorders and conversion disorders.

Pseudobulbar syndrome

Pseudobulbar syndrome usually occurs only against the background of bilateral damage to the cortical-nuclear pathways that go to the nuclei of the nerves of the bulbar group from the motor cortical centers.

This pathology is manifested by central paralysis of swallowing, impaired phonation and articulation of speech. Also against the background of pseudobulbar syndrome may occur:

• Dysphonia.

Video: Bulbar syndrome

However, unlike the bulbar syndrome, in these cases, atrophy of the muscles of the tongue does not develop. The palatine and pharyngeal reflexes are also usually preserved.

Pseudobulbar syndrome, as a rule, is observed against the background of dyscirculatory, acute disorders of cerebral circulation in both hemispheres of the brain, amyotrophic lateral sclerosis. It is considered less dangerous because it does not lead to violation of vital functions.

Diagnosis and treatment of bulbar syndrome

After consulting a therapist to diagnose bulbar syndrome, it is usually necessary to undergo a series of studies:

• General urine analysis;
• EMG of the muscles of the tongue, limbs and neck;
• General and biochemical blood test;
• CT or MRI of the brain;
• Esophagoscopy;
• Inspection of an ophthalmologist;
• Clinical and EMG tests for myasthenia gravis with a pharmacological load;
• Liquor research;

Depending on the clinical symptoms and the nature of the course of the pathology, the doctor can predict the outcome and effectiveness of the proposed treatment of the bulbar syndrome. As a rule, therapy is aimed at eliminating the causes of the underlying disease. At the same time, measures are taken to support and resuscitate impaired important body functions, namely:

Video: Exercise therapy for bulbar syndrome

• Breathing - artificial ventilation of the lungs;
• Swallowing - drug therapy with prozerin, vitamins, ATP;
• Salivation - the appointment of atropine.

It is quite important against the background of pseudobulbar and bulbar syndrome to carry out careful care of the oral cavity, and also, if necessary, observe patients during meals to prevent aspiration.

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