Review article

European Stroke Journal

0(0) 1–8
Oral care after stroke: ! European Stroke Organisation
2018
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DOI: 10.1177/2396987318775206
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Mary Lyons1,2 , Craig Smith3,4, Elizabeth Boaden1,

Marian C Brady5, Paul Brocklehurst6, Hazel Dickinson1,
Shaheen Hamdy7, Susan Higham8, Peter Langhorne9,
Catherine Lightbody1, Giles McCracken10,
Antonieta Medina-Lara11, Lise Sproson12, Angus Walls13 and
Dame Caroline Watkins1,14

Abstract
Purpose: There appears to be an association between poor oral hygiene and increased risk of aspiration pneumonia –
a leading cause of mortality post-stroke. We aim to synthesise what is known about oral care after stroke, identify
knowledge gaps and outline priorities for research that will provide evidence to inform best practice.
Methods: A narrative review from a multidisciplinary perspective, drawing on evidence from systematic reviews,
literature, expert and lay opinion to scrutinise current practice in oral care after a stroke and seek consensus on
research priorities.
Findings: Oral care tends to be of poor quality and delegated to the least qualified members of the caring team. Nursing
staff often work in a pressured environment where other aspects of clinical care take priority. Guidelines that exist are
based on weak evidence and lack detail about how best to provide oral care.
Discussion: Oral health after a stroke is important from a social as well as physical health perspective, yet tends to be
neglected. Multidisciplinary research is needed to improve understanding of the complexities associated with delivering
good oral care for stroke patients. Also to provide the evidence for practice that will improve wellbeing and may reduce
risk of aspiration pneumonia and other serious sequelae.
Conclusion: Although there is evidence of an association, there is only weak evidence about whether improving oral
care reduces risk of pneumonia or mortality after a stroke. Clinically relevant, feasible, cost-effective, evidence-based
oral care interventions to improve patient outcomes in stroke care are urgently needed.

Keywords
Stroke, oral health, oral hygiene, oral cavity, mouth, dental, pneumonia, quality of life, tooth-brushing
Date received: 3 December 2017; accepted: 12 April 2018

9
Institute of Cardiovascular and Medical Sciences, University of
1
Faculty of Health and Wellbeing, University of Central Lancashire, UK Glasgow, UK
2 10
Department of International Public Health, Liverpool School of Tropical Centre for Oral Health Research, School of Dental Sciences, Newcastle
Medicine, UK University, UK
3 11
Division of Cardiovascular Sciences, Manchester Academic Health Health Economics Group, Medical School, University of Exeter, UK
12
Science Centre, University of Manchester, UK National Institute for Health Research Devices for Dignity Healthcare
4
Department of Neurosciences, Salford Royal NHS Foundation Trust, UK Technology Cooperative, Sheffield Teaching Hospitals NHS Foundation
5
Nursing, Midwifery and Allied Health Professions Research Unit, Trust, UK
13
Glasgow Caledonian University, UK Edinburgh Dental Institute, College of Medicine and Veterinary
6
North Wales Organisation for Randomised Trials in Health, Bangor Medicine, University of Edinburgh, UK
14
Institute of Health and Medical Research and Salford Royal NHS Faculty of Health Sciences, Australian Catholic University, Australia
Foundation Trust, UK
7
Division of Diabetes, Endocrinology and Gastroenterology, School of Corresponding author:
Medical Sciences, Faculty of Biology, Medicine and Health, University of Mary Lyons, College of Health and Wellbeing, University of Central
Manchester, UK Lancashire, Brook Building, Preston, PR1 2HE, UK.
8
Institute of Psychology, Health and Society, University of Liverpool, UK Email: [email protected]
2 European Stroke Journal 0(0)

Introduction
Poor oral care after a stroke can have serious physical,
psychological and social consequences and adversely
affect quality of life.1–3
Aspiration pneumonia causes the highest attributable
mortality of all medical complications following stroke
and its prevention is therefore of paramount impor-
tance.4,5 There is a growing body of evidence to indicate
that poor oral hygiene increases the risk of pneumo-
nia.6,7 It would be rational to expect good oral hygiene
and plaque control in the early stages after a stroke to Figure 1. Trends in percentage of adults with 21 or more nat-
ural teeth by age, England 1978–2009.
reduce risk, but evidence for this is weak.8–10 Source: Oral health and function – a report from the adult dental
Dysphagia and loss of sensation affects up to 78% health survey 2009. NHS Information centre for health and social
of patients who have recently had a stroke and can care. Copyright! 2016, Re-used with the permission of the
cause stasis of saliva and food in the oral cavity.11–13 Health and Social Care Information Centre, also known as NHS
Reduced tongue pressure and altered lateral move- Digital. All rights reserved.
ments result in increased risk of aspiration as well as
causing food to pool in the sulci of the oral cavity health have in common is unclear.33 A scoping review
resulting in denture problems and stomatitis.14–16 of oral care post stroke found that stroke survivors
There also appears to be a higher than normal patho- aged 50 to 70 years have fewer natural teeth and are
genic bacterial and yeast count in the oral cavity in the more likely to wear dentures than a control group of a
acute phase of stroke.17,18 This combination increases similar age who had not had a stroke.19,34 A systematic
the risk of aspiration pneumonia.9,19–24 Approximately review found that patients with stroke had a poorer
10,000 microbial phylotypes have been identified in the clinical oral health status across a range of parameters
human oral microflora.25 There is a huge diversity of (tooth loss, dental caries experience and periodontal
bacterial organisms in the oral cavity of stroke patients. status).20 Other reviews have demonstrated an associa-
The balance between organisms may be as important tion between periodontal disease and stroke.33,35
for containing risk of aspiration pneumonia as the
presence or the absence of any particular bacteria in
What is to follow
the oral cavity.26
Whilst stroke can affect people of all ages, the aver- In this paper, we review the latest research on oral
age is 71 years.27 In many low and middle-income health in people who have had a stroke and the care
countries, the incidence of stroke is increasing but dilemmas this creates. We reflect on what people who
even in many European countries where it is decreas- have had a stroke and their carers think about the oral
ing, the size of the problem, based on the actual care patients receive and investigate the challenges of
number of new strokes is rising because of the ageing its provision in this population. We identify gaps in
population.27 Figure 1 shows the improving pattern of knowledge about optimum oral care for stroke patients
dentition between 1978 and 2009 in England. Although and areas where further research is needed to provide
considerably more people are surviving into old age the evidence to support best practice.
with some natural teeth, very few have excellent oral
health. Most have periodontal disease, a sizeable
Method
number of restorations (fillings and implants) and
need help to maintain their oral health.28,29 This is a narrative review, based on findings from sys-
The cost of dental care in the European Union is tematic reviews, primary research, other published lit-
expected to rise from e54 billion in 2000 to e93 billion erature combined with expert and lay opinion. It
in 2020.30 A significant proportion of this relates to the provides a holistic interpretation of the current situa-
provision of oral care for the growing number of tion in relation to oral care in stroke patients.
dependent older people – including those who have Consensus on knowledge gaps for optimum oral
had a stroke.31,32 care and research priorities was reached after a series
People who have a stroke tend to have worse oral of discussions with stroke survivors, carers, clinical and
health than the rest of the population but a cause and academic experts in dental care, health economics,
effect relationship cannot be assumed and the relative physical medicine, speech and language therapy, med-
importance of specific risk factors such as smoking, ical imaging, public health and nursing. It takes
poor nutrition and diabetes that stroke and poor oral account of the pluralities and diversities of the
Lyons et al 3

disciplines involved. An iterative process to synthesise Table 1. Key points.

the main issues and their implications, identify gaps
Oral care is perceived as important by patients, carers and
and directions for future research was undertaken professionals.52,53
through a series of meetings and discussions. The man-
Patients feel anxious and distressed about their appearance and
uscript was drafted and revised by all authors. worry that they may have halitosis.2,53

Lack of care is common and is a cause of distress for patients
and their families.52,54
Findings
Nurses make assumptions about patients’ ability to attend to
A prompt oral examination and assessment in patients their own oral care, and patients find it difficult to ask for what
who have had a stroke is important because it deter- they need.42,53

Relatives and friends express empathy but feel powerless to
mines oral hygiene needs, informs an oral care plan and
intervene and provide the care themselves.42,53
identifies problems that may affect recovery.36

Basic materials needed to provide good oral care are often
Available oral assessment protocols score features unavailable in stroke units.44
such as saliva, soft tissues and odour; with dental
There is uncertainty and fear about the best way to provide
plaque, oral function, swallowing, voice quality and oral care for stroke patients.51,53
hard tissue assessment suggested in some. However,
few oral assessment tools exist, and those that do, are
not specifically developed for, or validated in patients the disabling consequences such as paralysis, muscle
with stroke and are rarely used.19,37 Nurses are best weakness, cognitive impairment, fatigue, anxiety and
placed to conduct the initial oral assessment and can depression.45,46 Stroke patients often experience oral
also be trained to identify patients who may need refer- discomfort and pain, oral infections (especially oral
ral to a dental specialist.38 candidiasis) and difficulties in denture wearing.2,3,14,47
Dependent stroke survivors rely on nursing staff to Normal daily activities that affect oral hygiene such as
help them, but without evidence based pathways, ade- eating, drinking and tooth brushing can be severely
quate knowledge, skills, confidence and support from disrupted.48
senior staff and dental professionals, nurses cannot Table 1 summarises findings from studies exploring
provide effective, good quality oral care. stroke patients, carers and professionals experience of
Hospitalisation, reduced food and drink intake, oral care. Barriers such as fear of possibly causing
increased exposure to antibiotics and dependency can harm, lack of knowledge, skill or ability, lack of time,
affect stroke patients’ ability to maintain oral hygiene low priority, inadequate resources and lack of guidance
effectively.14,19 Dehydration and xerostomia can be a are the main explanations provided by carers and pro-
particular problem because of oxygen therapy, mouth fessionals for inadequate oral care provision in stroke
breathing, side-effects of medications and reduced food patients.1,49–51
and fluid intake.39,40 In these circumstances, oral care
can be challenging and is often given low priority Evidence
by nurses.41
Oral care can be further complicated where swallow There are few evidence-based assessment tools, guide-
safety is compromised, as patients may be unable to lines and protocols for oral care in the stroke popula-
keep any food residue, toothpaste or rinsing fluids tion.19,55,56 A Cochrane systematic review on staff-led
from entering their airway. interventions for improving oral hygiene following a
There is currently neither evidence nor consensus stroke was updated in 2011.1 The review included
guidance for best practice in assessment of need, equip- three trials. Gosney et al.57 found high carriage of
ment, procedure or how frequently oral care should be and colonisation by aerobic Gram-negative bacteria
provided. Practice in different locations varies widely in stroke patients. In this randomised controlled trial,
and staff feel insufficiently trained to deliver oral care the use of an oral decontaminating gel reduced the
effectively.19,42–44 The current lack of appropriate train- presence of bacteria and documented episodes of pneu-
ing and failure to prioritise oral care within the stroke monia, but mortality remained unchanged. Frenkel
care pathway has the biggest impact on patients with et al.58 found that education can improve caregivers’
greatest need who are at high risk of complications.10 knowledge, attitudes and oral care performance.
Fields59 found that the ventilator associated pneumo-
nia rate in an intensive care unit that included, but was
Patient, carer and
not specific to, stroke patients dropped to zero in the
professionals’ perspectives intervention group within a week of beginning a tooth-
For those who survive a stroke, life often changes dra- brushing regime. After six months, the control group
matically as they and their families learn to live with was dropped, and all intubated patients’ teeth were
4 European Stroke Journal 0(0)

Table 2. Recent oral care research.

Author Design Study Key findings

Smith et al., 201660 Mixed methods feasibility Staff education and training, and Interventions were feasible, acceptable and
study (29 patients, twice-daily brushing with chlor- raised knowledge and awareness.
10 staff) hexidine gel (or non-foaming
toothpaste) and denture care
if required.
Wagner et al, 201610 Quasi-experimental, n¼ To compare the proportion of Systematic oral health care was associated
1656 (949 in the inter- pneumonia cases in hospitalised with decreased odds of hospital-
vention group stroke patients before and after acquired pneumonia.
707 controls) implementation of an oral health
care intervention in the
United States.
Kuo et al, 201561 Randomised controlled To evaluate the effectiveness of a Poor oral hygiene and neglect of oral care
trial (RCT), n¼94 (48 in home-based oral care training was observed at baseline.
intervention group, programme for stroke survivors The intervention group had significantly
46 controls) in Taiwan. lower tongue coating and dental plaque
than the control group.
There was no difference in symptoms of
respiratory infection between
the groups.
Dai et al, 201520 Systematic review of Studies exploring oral health out- Patients with stroke had poorer oral health
observational studies comes and oral-health-related than healthy controls, and prior to the
behaviours in stroke patients. stroke tended to be less frequent dental
care attenders.
Horne et al, 201542 Qualitative study. Two Explored experiences and percep- Lack of understanding of the importance of
focus groups (n¼10) tions about the barriers to pro- oral care, inconsistent practice, lack of
viding oral care in stroke units in equipment and inadequate training for
Greater Manchester (UK). staff and carers.
Juthani-Mehta Non stroke-specific clus- Manual tooth/gum brushing plus Fewer cases of pneumonia in the inter-
et al, 201562 ter RCT, n¼834 (434 0.12% chlorhexidine oral rinse vention group, the difference was not
intervention, delivered twice a day and upright statistically significant.
400 control) feeding position was compared to
usual care in nursing homes in the
United States.
Chipps et al, 20148 Randomised controlled A standardised oral care interven- Subjects in both groups showed improve-
pilot study, n¼51 tion performed twice a day was ment in their oral health assessments,
(29 intervention, compared to usual care in a swallowing and oral intake over time,
22 control) stroke rehabilitation setting in the but the difference was not statistically
United States. significant.
Staphylococcus aureus colonisation in the
control group almost doubled (from
4.8% to 9.5%), while colonisation in the
intervention group decreased (from
20.8% to 16.7%) but again differences
were not statistically significant.
Kim et al, 201447 RCT n¼56 (29 interven- Impact of an oral care programme Plaque index, gingival index and presence
tion, 29 control) delivered to patients who had of candida in the saliva were significantly
recently experienced their first lower in the intervention compared to
stroke in the intensive care unit of the control group. There was no signif-
a university hospital in Korea. icant difference between the groups in
clinical attachment, tooth loss or pres-
ence of Candida albicans on the tongue.
Seguin et al, 201463 RCT, n¼179 (91 inter- A non-stroke-specific trial con- No evidence to recommend oral care with
vention, 88 control) ducted in six intensive care units povidone-iodine to prevent ventilator-
in France. The intervention con- associated pneumonia in high-risk
sisted of washing the oropharyn- patients. The use of povidone-iodine
geal cavity with diluted povidone- seemed to increase the risk of acute
iodine or placebo. respiratory distress syndrome.
(continued)
Lyons et al 5

Table 2. Continued
Author Design Study Key findings

Lam et al, 2013 64

RCT, n ¼ 102 (33 in group Three groups in a stroke rehabilita- Poor oral hygiene was noted in all groups
1, 34 in group 2, 35 in tion ward in Hong Kong were at baseline. Significant reductions in
group 3) provided with an electric tooth- dental plaque and gingival bleeding were
brush and standard fluoride noted in both intervention groups 2 and
toothpaste. Group one received 3 compared to group 1. The impact on
oral hygiene instruction only, pneumonia could not be ascertained as
group two received this plus no cases were recorded.
chlorhexidine mouthwash and
group three received the same as
two, plus assistance with brushing
twice a week.
Lam et al, 201265 Literature review A review of non-stroke-specific The effects of antiseptic agents could not
studies that evaluated the effec- be discerned from the adjunctive
tiveness of oral hygiene interven- mechanical oral hygiene measures. High-
tions in reducing oropharyngeal quality RCTs are needed to determine
carriage of aerobic and faculta- which combinations of oral hygiene
tively anaerobic gram-negative interventions are most effective in
bacilli (AGNB) in medically com- eliminating or reducing AGNB carriage.
promised patients.

brushed every 8 hours, maintaining a zero rate of Several guidelines refer to oral care following a
ventilator-associated pneumonia until the end of the stroke (See Supplementary Appendix 1 which will be
two-year study. Lack of adequate data meant that the available online with this article, http://journals.sage
findings were not included in the meta-analysis. pub.com/doi/full/10.1177/2396987318775206). Many
The Cochrane review concluded that provision of refer to the lack of evidence to support detailed guid-
training in oral care interventions can improve staff ance. Answers to basic questions about whether it is
knowledge and attitudes, cleanliness of patients’ den- best to use an electric or manual toothbrush, size and
tures and reduce incidence of pneumonia. However, type of head, which – if any toothpaste, how frequently
evidence was weak and improvements in the cleanliness care should be given, etc. are not provided. No guide-
of patients’ teeth were not observed. Table 2 provides lines contain information or advice to alleviate nurses’
an overview of the relevant research published on oral anxieties about how best to reduce risk of choking
care in stroke patients since the 2011 Cochrane when delivering oral care for dysphagic stroke patients.
review update. It is a limitation of this study that there is little evi-
dence about oral care practice in stroke units across
Europe, hence most of the included studies are
Discussion from elsewhere.
Adequate oral care improves patients’ oral health,
comfort and quality of life, but definitive evidence of Future considerations
its ability to reduce the risk of pneumonia is lacking.55 Emerging evidence supports the rationale for develop-
Two non-stroke specific nursing home based studies, ing best practice guidelines for oral care in stroke care
one from Japan (2002) and the second from the units.19 High-quality evidence is needed to inform
United States (2008) evaluated the impact of an oral improvements in staff training and delivery of consis-
care intervention in a setting where there were a tent oral care. Protocols need to be developed that
number of stroke patients.6,66 Both studies reported focus on maintenance of dentition and a quality of
fewer cases of pneumonia (or related death) amongst life associated with having acceptable oral function.
residents that received oral health care but the Japanese Protocols need to describe simple preventative meas-
trial excluded incapacitated, dysphagic, unstable and ures at every stage in the care pathway, combined
unconscious residents.6 Unfortunately, in many trials with early diagnosis and management of significant
the challenges associated with gaining informed con- dental pathology. Several oral hygiene interventions
sent result in patients who are most dependent for appear to be feasible and well-tolerated in early-stage
oral care being excluded. studies.47,55,59,60,63,64
6 European Stroke Journal 0(0)

Research is needed to inform the spectrum and var- Ethical approval

iation in existing ‘usual’ care and service provision Not applicable as this is a review article and contains no
(including the role of specialist dental services) as well primary research.
as optimal oral assessment tool(s), including for
patients who are intubated as well as later during the Guarantor
rehabilitation phase. CLW.
Safety, acceptability and resources required to deliv-
er high-quality oral care assessments and protocols Contributorship
needs to be established. CW and CS devised the conceptual framework. CS, EB,
Clarity is needed about the multi-disciplinary team MCB, HD, ShH, SH, ML and GMcC contributed sections
support required, especially around optimisation of to this paper. ML synthesised contributions with support
effective staff education and training, including from from PL, CL, AM-L, LP, AW and CW. All authors reviewed,
dental specialists. edited and approved the final version of the paper.
Ultimately, large phase three randomised trials sup-
ported by realistic recruitment and clinically relevant Acknowledgements
strategies, economic evaluation and implementation Mary Harrington, Head of Speech & Language Therapy,
strategies are required. They need to produce practical Hull & East Yorkshire Hospitals NHS Trust reviewed and
clinical outcomes that address barriers and facilitators commented on the paper.
to change and adoption of evidence into policy
and practice. ORCID iD
Priority should be given to research that provides Mary Lyons http://orcid.org/0000-0001-7532-2301
evidence to inform standards for oral care delivery,
and guidelines for each patient with individualised References
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