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. 2026 Jan 28;26:355. doi: 10.1186/s12903-026-07766-0

Health professionals’ barriers to oral care provision for patients with stroke from multidisciplinary perspectives: a qualitative meta-synthesis using the COM-B model and theoretical domains framework

Xingru Li 1,2, Chao Zhang 2,✉, Wenhao Zhang 1,2, Wenguang Xie 1,2, Shilin Liu 1,2, Wei Xiao 1,2, Shuyuan Huang 1,2
PMCID: PMC12924374  PMID: 41593577

Abstract

Background

Patients with stroke often have poor oral health due to functional impairments. Healthcare professionals play a crucial role in providing oral care, yet such care is frequently assigned low priority. Existing reviews primarily focus on the experiences of nurses in delivering oral care to patients with stroke. Few studies focus on multidisciplinary perspectives. This study aims to synthesize evidence on barriers faced by multidisciplinary healthcare professionals in providing oral care to patients with stroke, using the COM-B model and the Theoretical Domains Framework (TDF).

Methods

Six English databases (PubMed, Cochrane Library, Embase, Scopus, Web of Science, and CINAHL) were searched from their inception to July 1, 2025. The screening process followed the PRISMA guidelines. Study quality was assessed using the Critical Appraisal Skills Programme checklist. Data synthesis was guided by the thematic synthesis approach for qualitative research proposed by Thomas and Harden (2008). Confidence of synthesized findings was assessed using the GRADE-CERQual framework.

Results

The initial search identified 895 records retrieved from electronic databases. Nine studies were included in the review, which yielded a total of 7 summary findings. Health professionals’ barriers to oral care provision in patients with stroke included knowledge (Lack of knowledge and skills), skills (Lack of skills), environmental context and resources (lack of standardized guidelines and care planning, resource allocation defects), social influences (HCPs’ perceptions of patient characteristics), beliefs about capabilities (lack of confidence and risk concerns), social/professional role and identity (multidisciplinary role expectation conflicts).

Conclusions

This review represents the first meta-synthesis to explore barriers to oral care provision for patients with stroke from the perspective of multidisciplinary HCPs, underscoring the need for multifaceted interventions to improve oral care practices.

Trial registration

PROSPERO [CRD420251088856].

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-026-07766-0.

Keywords: Stroke, Oral health, Oral care, Barrier, Health professional, Qualitative study, Meta-synthesis

Introduction

Among non-communicable diseases, stroke ranks as the second leading cause of death and the third leading cause of disability [1]. With advancing population aging, the prevalence of stroke is projected to rise substantially. Concomitant physical disabilities often impair individuals’ ability to maintain oral hygiene. Previous studies [2, 3] have indicated that upper limb impairments and muscle spasticity in the shoulder and wrist compromise stroke patients’ ability to use oral care tools, thereby contributing to poorer oral hygiene. In addition to physical disabilities, stroke-induced brain lesions commonly precipitate orofacial dysfunction, affecting nearly 80% of individuals with stroke [4], which directly compromises speech, mastication, deglutition, and oral clearance. Meta-analyses demonstrate significantly poorer oral health in patients with stroke versus non-stroke controls, evidenced by increased tooth loss, higher caries incidence, and more severe periodontal disease [5, 6]. For stroke patients with dysphagia, the proliferation rates of opportunistic pathogens in the oral cavity are higher [7], which increases the risk of aspiration pneumonia, malnutrition, and other adverse outcomes [8, 9]. Maintaining oral hygiene represents a key measure in preventing aspiration pneumonia [10].

Given these functional limitations, individuals with stroke in acute and rehabilitation settings often require staff-assisted oral care [11, 12], including early identification, assessment, oral cleaning, and referral [13]. Currently, most guidelines emphasize the necessity of oral care after stroke [14, 15]. However, its provision is frequently suboptimal compared with other stroke-related care [16]. Although healthcare professionals (HCPs) have the potential to promote oral health in individuals with stroke [17], the execution of oral care in practice is still not ideal. A multicenter cross-sectional study reported that only one-third of nurses performed or assisted with daily oral care for patients with stroke [18]. A mixed-methods study found that oral assessments were conducted daily in only 3 out of 11 stroke units [19]. Therefore, improving this situation requires understanding the difficulties encountered by HCPs in providing oral care.

A preliminary search identified a systematic review [20] that examined social and behavioral factors of oral health in patients with acquired brain injury (primarily stroke). However, only one study in that review referred to barriers encountered by HCPs, such as communication issues, competing tasks, and the complexity of oral care [21]. Furthermore, one scoping review [22] identified challenges in oral care provision by non-dental professionals, primarily including time constraints and reluctance to undergo additional training. However, this review mainly focused on nursing staff. It has been reported that multidisciplinary teamwork can improve oral health and reduce the incidence of stroke-associated pneumonia [23, 24]. Clinical consensus also emphasizes the need for multidisciplinary perspectives to enhance understanding of the complexities of delivering effective oral care for patients with stroke [14].

Applying a theoretical framework can help identify key determinants of barriers. The Theoretical Domains Framework (TDF), comprising 14 domains, was initially developed to provide a comprehensive, theory-based approach for identifying determinants of behavior [25, 26] and has been widely used across various healthcare settings [27, 28]. The Capability, Opportunity, Motivation-Behavior (COM-B) model posits that capability, opportunity, and motivation interact to generate behavior. The domains of the TDF can be mapped onto these three key components of the COM-B model [29]. Using the COM-B model and the TDF, intervention designers can identify what needs to be changed to facilitate desired behaviors (i.e., barriers).

To gain in-depth insights into this topic, we planned to focus on qualitative studies and conduct a meta-synthesis based on the COM-B model and the TDF, as more and more studies have noticed barriers to HCPs in the delivery of oral care for stroke patients, but they are dispersed, based on different contexts and foci. Moreover, qualitative research, compared to quantitative studies, enables a deeper understanding of the personal experiences and nuances of multidisciplinary HCPs in oral care provision. To our knowledge, no review has synthesized evidence on oral care barriers in the context of stroke from the perspective of multidisciplinary HCPs.

Methods

Aims

This study aims to synthesize oral care barriers to patients with stroke from multidisciplinary HCPs’ perspectives and map these factors onto the TDF and COM-B model. The research question to be addressed was: What barriers or challenges did HCPs experience in oral care for patients with stroke?

Design

A qualitative meta-synthesis reporting adhered to the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) guidelines. The protocol was registered on PROSPERO (registration number CRD420251088856).

Search methods

Six English databases (PubMed, Cochrane Library, Embase, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL)) were searched from their inception to July 1, 2025.

The search strategy was developed based on the PEO framework: Population (P), HCPs, including but not limited to: nurse, occupational therapist, physiotherapist, speech and language therapist, dental professional, and dietician; Exposure (E), oral or dental care for patients with stroke; Outcome (O), barriers, difficulties, and challenges. Database searches employed terms for each concept, with truncation applied where appropriate. Terms within the same concept were combined using the ‘OR’ Boolean operator. The resulting concept groups were then combined using ‘AND’. To prevent omissions, reference lists of relevant systematic reviews were checked, and the relevant studies were sought through manual searching. The complete search strategy, with PubMed as an example, is provided in Supplementary File 1.

Literature screening

The screening process followed the PRISMA guidelines [30]. Initially, all retrieved articles were imported into EndNote, and duplicates were removed. Subsequently, two reviewers (LXR, ZWH), who were trained in evidence-based medicine, independently screened articles based on titles and abstracts against the predefined inclusion and exclusion criteria (see Table 1). The full text of the remaining articles was then independently assessed by the two same reviewers to determine final inclusion. Any disagreements arising during this process were resolved through discussion with a third reviewer (ZC).

Table 1.

Eligibility criteria

Inclusion Criteria Exclusion Criteria

Population: HCPs with experience working with patients with stroke.

HCPs are defined as individuals who, based on extensive theoretical and factual knowledge, research, advise, or provide preventive, curative, rehabilitative, and health-promoting services in the diagnosis and treatment of diseases and other health problems [53].

HCP Assistant

Intern student

Trainee
Interest: Focuses on barriers, challenges, or difficulties encountered by HCPs in providing oral care to adults diagnosed with stroke. Oral care targets involve individuals with neurological disorders other than stroke.
Design: Qualitative research or mixed-method studies with reporting of qualitative results. For mixed-methods studies, only the qualitative component was extracted for further analysis.

Quantitative studies, conference abstracts, case reports, protocols, systematic reviews, and other types of reviews.

Mixed-methods studies where qualitative results could not be extracted separately.

Studies examining the effectiveness of oral care interventions were excluded.
Setting: No restrictions.
Studies published in English as full-text articles in peer-reviewed journals were eligible. Studies not published in English. Duplicate publications or studies for which full text was unavailable.
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Quality appraisal

The methodological quality of included studies was assessed using the Critical Appraisal Skills Programme (CASP) tool for qualitative studies [31]. This tool comprises 10 questions, each with answers of “Yes”, “No”, or “Unclear”. LXR and ZWH independently performed the assessment. Any disagreements were resolved through discussion with ZC. No scoring was applied during the assessment process. All studies meeting the selection criteria were included regardless of methodological quality, as methodologically weaker studies may offer unique insights not found in stronger studies [32]. Each study was deemed to provide a valuable perspective relevant to the aims of this review.

Data extraction

LXR and ZWH independently extracted qualitative data (findings and analytical sections) from the included studies and then entered them into Microsoft Excel software. Key descriptive characteristics of the included studies (e.g., author, year, country, setting, sample, methodology, aims, key barriers, and related quotes) were extracted using a pre-designed form. Any disagreements were resolved through discussion with ZC.

Synthesis

The data synthesis was guided by Thomas and Harden’s (2008) thematic and content analysis methodology of synthesising qualitative studies [33]. Prior to synthesis, three reviewers (LXR, ZWH, and ZC) repeatedly read the included studies to become familiar with them. Following the first stage of thematic analysis, all findings and explanations were inductively coded line-by-line based on their meaning and content; LXR performed this stage. In the second stage, LXR and ZWH reviewed all codes to identify similarities and differences, grouping them into broader categories based on semantic similarity. Each category was assigned a concise description, and from these categories, descriptive themes were developed to characterize the various barriers faced by HCPs in providing oral care to individuals with stroke. Subsequently, LXR and ZWH conducted a further interpretative analysis to generate analytical themes. These themes extend beyond the descriptive findings of the original studies, offering a synthesized understanding of the barriers faced by HCPs in providing oral care to individuals with stroke. These analytical themes are referred to in this review as summary findings. Finally, these summary findings were mapped into the COM-B model and TDF. First, LXR and ZWH independently reviewed each summary finding and identified which domain of the TDF it belonged to. These domains were further mapped to the corresponding components of the COM-B model. Throughout this process, any disagreements were resolved through discussion with ZC. All researchers reviewed the data analysis process to ensure interpretive consistency and the adequacy of the analytical themes. It is important to note that some statements may span multiple components of the COM-B model. For example, the phrase “If it is more severe…I’m not particularly confident with actually intervening” intuitively reflects a lack of confidence, which corresponds to the “beliefs about capabilities” component of the COM-B model. Although it may also imply a deficit in HCPs’ abilities, relating to the “physical capability” component as well. However, in this review, the thematic deductive approach based on the framework prioritizes the intuitive meaning of such statements. Specific details are shown in Fig. 1.

Fig. 1.

Fig. 1

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Development of descriptive themes and analytical themes

Assessment of confidence in evidence synthesis

The Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual) approach was used to assess the confidence in each review finding [34]. CERQual provides a systematic and transparent framework incorporating four components: methodological limitations (assessed by the CASP tool), coherence (about the internal consistency of synthesized conclusions), adequacy (concerning the richness and sufficiency of the data), and relevance (referring to the congruence between the context of the primary studies and the review question). Confidence levels were categorized as high, moderate, low, or very low. All findings initially started with high confidence and were downgraded if any issues were identified in the GRADE-CERQual components. The evaluation process was carried out independently by LXR and ZWH, and any disagreements were discussed with ZC.

Results

Results of the search

The initial search identified 895 records retrieved from electronic databases, and six records were identified through manual searching. After removing 122 duplicate records, 745 records were excluded based on title and abstract screening against the inclusion and exclusion criteria. The full texts of the remaining 34 articles were retrieved for further assessment of eligibility. After carefully examining the full texts, nine studies were ultimately included for qualitative synthesis. The search results and process are illustrated in Fig. 2.

Fig. 2.

Fig. 2

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PRISMA flowchart of the literature search

Characteristics of included studies

All included studies were published between 2015 and 2024. Among the nine studies, sample sizes ranged from 5 to 30 HCPs. Five studies utilized focus group interviews and four employed semi-structured interviews. Most studies explored barriers faced by HCPs in providing oral care to patients with stroke, while one specifically explored barriers related to stroke patients with dysphagia. A total of 28 key barriers were identified from the included studies (see Table 2).

Table 2.

Summary of reviewed studies

First author /Publish time Setting/ Country Sample Methods Aims Key barriers
O’Malley L [35], 2020 Hospital, UK N = 19 (2 dieticians, 7 speech and language therapists, 2 nurses, 2 occupational therapists, 1 physiotherapist, 2 dental care practitioners, 1 consultant in restorative dentistry, 3 professional carers) A qualitative study/Focus group/A thematic analysis To explore experiences of and barriers to oral care, particularly in relation to oral hygiene practice and dental attendance, among stroke survivors in the community.

1) Gaps in staff training and confidence in supporting patients with oral care;

2) Access to dental services is problematic.
Hammond L [37], 2023

Stroke ward of

a tertiary hospital, Australia

 N = 11 (8 nursing staff members, 3 speech language pathologists) A qualitative study/Semi-structured interviews/A thematic analysis

To investigate the

perceptions of oral care delivery held by nurses and speech language pathologists.

1) Limited education;

2) Not enough time;

3) Not a priority;

4) Fear;

5) Patient non-consent to oral care.
Ferguson C [40], 2020 Metropolitan public hospitals, Australia N = 21 (18 nurses, 2 physiotherapists, 1 speech pathologist)

An exploratory qualitative

Design/ Focus group/A thematic analysis

To explore the perspectives of

nursing and allied health stroke clinicians regarding oral care for stroke patients across acute care and stroke rehabilitation settings.

 Inadequate knowledge, resources and training.
Horne M [19], 2015 Hospital, UK N = 5 (2 staff uurses, 3 clinical support workers) Mixed-methods/A qualitative study/Focus group/A framework approach To explore stroke survivors’, carers’ and healthcare professionals’ experiences and perceptions about the barriers and facilitators to receiving and undertaking oral care in stroke units.

(1) Lack of protocols and assessment tools;

(2) Lack of education and training;

3) Inconsistency in the delivery of oral care.
Konadu AB [13], 2024 Hospital, Ghana and Nigeria N = 25 (14 nurse practitioners, 7 medical doctors, 4 physiotherapists) A qualitative study/Face-to-face semi- structured interview/An inductive approach

To explore the perception and

practices of health care professional oral health care of stroke patients managed in the acute stroke care setting.

1) Lack of collaboration and integration;

2) Lack of standardization of tools;

3)Insufficient equipment;

4) Focus on other clinical needs.
BaHammam F [39], 2024 National health service premises, UK N = 30 (4 physicians, 5 dentists, 5 speech and language therapists, 14 nurses, 1 dental hygienist, 1 dental therapist)

A qualitative

study/Semi-structured interview/ The constant comparative approach

To explore

implementation issues and potential barriers for assessing oral health in dependent post- stroke patients.

1) Patient-related barriers;

2) Service provider-related barriers;

3) Environment-related barriers.
Curtin C [38], 2024 Stroke unit, UK

N = 12 (1 dietician, 1 occupational therapist, 4 nurses,

3 physiotherapists, 1 doctor, 2 speech and language therapists)

A qualitative

study/Focus group/A thematic analysis

 To explore the attitudes, facilitators, and barriers in providing oral care for inpatients with dysphagia post-stroke as perceived by healthcare professionals.

1) Lack of confidence and concerns;

2) Unique challenges;

3) Lack of resources and time;

4) Competing demands.
BaHammam F [41], 2023 National health service premises, UK N = 30 (4 physicians, 5 dentists, 5 speech and language therapists, 14 nurses, 1 dental hygienist, 1 dental therapist)

A qualitative

study/Semi- structured interview/The constant comparative approach

To explore experiences and views of health service providers about the

causes of oral health decline in patients after stroke.

1) The patient;

2) The service providers;

3) The environment.
Klaic M [36], 2022 Acute stroke unit and inpatient stroke rehabilitation unit, Australia

N = 14 (3 nurses, 4

speech pathologists, 3 occupational therapists, 2 physiotherapists, 2 dietitians)

Mixed-methods approach/A qualitative

study/Focus group/The TDF

To explore oral hygiene enablers and barriers

with the multidisciplinary stroke team.

1) Lack policies and guidelines;

2) Low belief;

3) Lack documentations.
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Quality assessment of the included studies

All studies clearly articulated the rationale for employing qualitative designs. All studies adequately described their data collection methods and clearly presented their findings. All studies sufficiently addressed the relationship between the researcher and participants, except for three studies [13, 19, 35]. Furthermore, one study did not consider ethical issues [36] (see Table 3).

Table 3.

Critical appraisal

First author /Publish time Was there a clear statement of the aims of the research? Is a qualitative methodology appropriate? Was the research design appropriate to address the aims of the research? Was the recruitment strategy appropriate to the aims of the research? Were the data collected in a way that addressed the research issue? Has the relationship between the researcher and participants been adequately considered? Have ethical issues been taken into consideration? Was the data analysis sufficiently rigorous? Is there a clear statement of findings? How valuable is the research?
O’Malley L [35], 2020 P P P P P ? P P P P
Hammond L [37], 2023 P P P P P P P P P P
Ferguson C [40], 2020 P P P P P P P P P P
Horne M [19], 2015 P P P P P ? P P P P
Konadu AB [13], 2024 P P P P P ? P P P P
BaHammam F [39], 2024 P P P P P P P P P P
Curtin C [38], 2024 P P P P P P P P P P
BaHammam F [41], 2023 P P P P P P P P P P
Klaic M [36], 2022 P P P P P P O P P P
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P, Yes; O, NO; ?, Unclear

Synthesised findings and assessment of confidence

An analysis of the 9 included studies yielded a total of 7 summary findings, which were mapped onto the 6 TDF domains, namely, knowledge (Lack of knowledge), skills (Lack of skills), environmental context and resources (lack of standardized guidelines and care planning, resource allocation defects), social influences (HCPs’ perceptions of patient characteristics), beliefs about capabilities (lack of confidence and risk concerns), social/professional role and identity (multidisciplinary role expectation conflicts). These were further linked to the three components of the COM-B model.

Using the GRADE-CERQual approach to assess confidence in the evidence, seven summary findings achieved “high confidence.” Synthesised findings and CERQual assessment of confidence are presented in Table 4.

Table 4.

Synthesised findings and cerqual assessment of confidence

COM-B Model TDF Domain Summary findings Studies contributing to the review CERQual assessment of confidence in the evidence Explanation of CERQual assessment

Capability

(Psychological capability)

 Knowledge Lack of knowledge [19, 35, 36, 38, 40] High

5 studies with no or very minor concerns about methodological limitations, coherence, adequacy, and relevance.

(2 studies with no concerns and 3 studies with minor concerns on unclear reflexivity [19, 35] and unspecified ethical issues [36])

Capability

(Physical capability)

 Skills Lack of skills [13, 19, 37, 39, 40] High

5 studies with no or very minor concerns about methodological limitations, coherence, adequacy, and relevance.

(3 studies with no concerns and 2 studies with minor concerns on unclear reflexivity [13, 19])

Opportunity

(Physical environment)

 Environmental context and resources Lack of standardized guidelines and care planning [13, 19, 35–41] High

9 studies with no or very minor concerns about methodological limitations, coherence, adequacy, and relevance.

(5 studies with no concerns and 4 studies with minor concerns on unclear reflexivity [13, 19, 35] and unspecified ethical issues [36]

Opportunity

(Physical environment)

 Environmental context and resources Resource allocation defects [19, 19, 35, 36, 38–41] High

8 studies with no or very minor concerns about methodological limitations, coherence, adequacy, and relevance.

(4 studies with no concerns and 4 studies with minor concerns on unclear reflexivity [13, 19, 35] and unspecified ethical issues [36]

Opportunity

(Social environment)

 Social influences HCPs’ perceptions of patient characteristics [13, 19, 35–41] High

9 studies with no or very minor concerns about methodological limitations, coherence, adequacy, and relevance.

(5 studies with no concerns and 4 studies with minor concerns on unclear reflexivity [13, 19, 35] and unspecified ethical issues [36]

Motivation

(Reflective motivation)

 Beliefs about capabilities Lack of confidence and risk concerns [13, 19, 35–38] High

6 studies with no or very minor concerns about methodological limitations, coherence, adequacy, and relevance.

(2 studies with no concerns and 4 studies with minor concerns on unclear reflexivity [13, 19, 35] and unspecified ethical issues [36]

Motivation

(Spontaneous motivation)

 Social/professional role and identity Multidisciplinary role expectation conflict [13, 36–38, 40] High

5 studies with no or very minor concerns about methodological limitations, coherence, adequacy, and relevance.

(3 studies with no concerns and 2 studies with minor concerns on unclear reflexivity [13] and unspecified ethical issues [36]
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Findings

Theme of capability

Lack of knowledge (TDF domain: knowledge)

HCPs, especially nurses, reported a lack of knowledge of oral care regarding special patients, such as those who are fasting or have difficulty swallowing. They reported that their undergraduate education covered oral care for the general population but lacked depth regarding special populations. This gap extended to other HCPs: Physiotherapists expressed uncertainty about oral care specifics, and dietitians reported minimal involvement due to inadequate knowledge in this area. Notably, community nurses reported that they were unaware of the consequences of not brushing for individuals with stroke.

I can’t really recall learning too in-depth into like specific oral care. It was more just like everyone’s got teeth, this is how you brush them. (Nurse) [37].

I wouldn’t be aware, you know, I would give them general advice, but I wouldn’t know if there were any specifics or whatever. (Physiotherapist) [38].

Lack of skills (TDF domain: skills)

Most HCPs expressed that undergraduate education focuses on the theory section, and practical skills in oral care were typically acquired informally and non-systematically on the job, often through observation or peer discussions. Consequently, the quality and content of this training varied significantly depending on the instructor.

It was only one theory section, that’s it, nothing else, and we just learned from the job, that’s it. (Nurse) [38].

But I guess it depends, like, what nurse you are working with as well. Some people do it better than others, I should say. (Nurse) [37].

Theme of opportunity

Lack of standardized guidelines and care planning (TDF domain: environmental context and resources)

Nurses consistently reported the absence of oral care standardized guidelines and protocols for patients with stroke. The quality of oral care was largely dependent on nurses’ experience rather than established best practices.

I think there were standards…we didn’t have a policy at that hospital, about how you managed somebody’s mouth. (Nurses) [19].

…It just depends on everybody. I think we do a good job, but there are just very inconsistent practices with everybody. (Nurse) [37].

Furthermore, oral care was omitted from routine nursing care and discharge plans. Unlike other care aspects (e.g., pressure ulcer care, fluid balance), oral care assessments and interventions were typically excluded from medical records, which hindered HCPs’ ability to track oral status or identify causes of deterioration. The evaluation process also lacked clarity, with staff uncertain about how to interpret or act on the assessment scores.

Because even in a hospital, there are care plans for all sorts of things, but there isn’t an oral hygiene care plan, is there? (Speech and language therapist) [35].

Oral care is inadequate. I must say it is not part of our core discharge plans, which we should be doing. (Doctor) [13].

It’s good just to get the scores and then generate. But then what do you do with it? You know, that’s the problem. (Nurse) [39].

Resource allocation defects (TDF domain: environmental context and resources)

Most HCPs reported a shortage of basic oral care equipment, such as dental mirrors and suitable toothbrushes, as well as inadequate hospital stock, forcing them to use unsuitable alternatives or request supplies from patients’ families. Additionally, inadequate staffing and time pressures led to irregular oral care, which was frequently deprioritized when competing with other clinical tasks.

So you end up having to ring the families and ask them to bring it in if someone doesn’t have it. Oralieve can sometimes be in short supply, and they don’t have enough stock that I think. (Speech and language therapist) [38].

It’ll happen at a random time when we can-You know what I mean? It’s not like we brush them-you know, do it in the morning or intermittently, or as they need-it’s sort of when we can. (Nurse) [37].

Dental service shortages were reported more frequently in Australia. When encountering complex oral health issues, HCPs discuss cases in team meetings. Access to specialized dental consultation or services was generally limited except for major dental issues. Nurses reported that the most common referral pathway was ‘telling them to go to their own dentist.’ [40] Some nursing staff were even unaware of the availability of dental services for inpatients.

We don’t have access to the dental hospital. We don’t have routine access; it’s like if something is falling out or breaking out of your mouth, great, but otherwise we have very limited access to dental services. (Speech and language therapist) [38].

HCPs’ perceptions of patient characteristics (TDF domain: social influences)

HCPs reported that they had difficulties in assessing the oral health status of individuals with stroke, as individuals often struggle to follow instructions due to cognitive and communication impairments, such as aphasia. Some HCPs also noted ‘language barrier or communication…’ due to cultural differences.

If they have reduced understanding after their stroke, they may not be able to follow instructions. (Doctor) [38].

It can be hard to assess pain if someone’s having difficulty communicating after a stroke. (Speech and language therapist) [39].

In addition, HCPs noted low patient willingness during oral care provision, typically influenced by economic factors (e.g., concerns about the cost of dental services), psychological factors (e.g., post-stroke embarrassment, distress, or worry about adding to HCPs’ workload), limited understanding of oral care (e.g., perceiving it as intrusive), and patient preferences.

We have a lot of people, too, from very poor socio-economic backgrounds, and that’s not something they put high on their agendas, unfortunately. (Allied health clinicians) [40].

A facial droop can also lead to drooling. which I think again people can sometimes be very self-conscious of and very embarrassed about. (Nurse) [41].

Some HCPs, such as therapists and physicians, expressed that they have limited contact and communication with patients with stroke compared to nurses, which hinders the development of rapport, ultimately reducing patients’ compliance with therapists.

[therapist] We see the patients, but we see them for an hour at a time, whereas, you’re [nurses] are seeing them the full day. We see them for those pockets of time, and that’s it, and so you get to build up a rapport with the patient… (Therapist) [19].

Theme of motivation

Lack of confidence and risk concerns (TDF domain: beliefs about capabilities)

Most HCPs reported a lack of confidence in performing oral assessments and care, particularly for patients with severe or complex conditions.

If it is more severe. I’m not particularly confident with actually intervening. (Speech pathologist) [36].

But then I would say that, being just a general ward doctor, I don’t think I’d be very good at doing a proper dental assessment. (Doctor) [39].

The risk of aspiration during oral assessment and care was a frequently cited concern, especially for patients with dysphagia. These safety concerns prompted caution and nervousness, making HCPs avoid or minimize oral care for high-risk individuals. Furthermore, the aggressive behaviors of individuals with stroke made HCPs weigh the pros and cons before oral care.

I suppose even the fact that they are on say thickened fluids or whatever, and then you are providing oral care with unthickened fluids, you would be a bit cautious. (Dietician) [38].

Sometimes I would be worried about their aspiration risk, or they are orally dyspraxic. I’m like “Oh, I am going to stay away from that.” (Occupational therapist) [36].

Multidisciplinary role expectation conflict (TDF domain: social/professional role and identity)

Although nurses and speech-language pathologists were identified as key personnel for oral care in patients with stroke, a phenomenon of responsibility shifting often occurs in actual practice. Some speech-language pathologists believed they should perform oral care both before and after patient meals. Others felt oral care extended beyond their traditional role.

…I’ll try and educate the nurse so I’ll get them to come in so they can see whatever I’ve just pulled out of their mouth. (speech-language pathologist) [37].

It’s not traditionally our role. I’ve not been providing oral care for oral care’s sake; I’ve been providing oral care as part of my swallowing assessment. (Speech and language therapist) [37].

Doctors and physiotherapists were seen as having a potential role in oral care. However, doctors usually confined their role to initial screenings and passed on subsequent care to nurses. Occupational and physiotherapists primarily saw their role as promoting patient independence or advising nurses, rather than performing direct care. Furthermore, the addition of dental staff to stroke units was also seen by some Australian nurses as threatening their jobs or as a reason to stay away from their own duties. As a nurse said, “Why do we need to do it, we’ve got a dental assistant?” (Nurse) [37].

Aside from the initial assessment… but the doctors hardly even look into the mouth. It is the nurses who do this when they clean the patient’s mouth. (Doctor) [13].

We would be liaising with the nurses, saying continue the Yankauer suction to clear their mouth. (Physiotherapist) [38].

Discussion

This review represents the first meta-synthesis to explore barriers to oral care provision for individuals with stroke from the perspective of multidisciplinary HCPs, using the COM-B model and the TDF. The findings broaden the scope of previous reviews, which have primarily focused on nursing staff [22], by identifying multifaceted barriers that influence HCPs’ capability, opportunity, and motivation to deliver oral care. A deeper understanding of these factors can inform the development of targeted interventions to improve oral health practices in stroke care.

Ajwani et al. [22] suggest that nursing staff lack knowledge regarding oral health care. However, in this study, other HCPs, including physicians, linguists, physiotherapists, and dentists, also self-reported a deficiency in oral care knowledge. Inadequate education and training contribute to limited knowledge and skills among HCPs regarding oral care, resulting in a lack of confidence, risk aversion, and role avoidance. Future efforts should focus on delivering structured, skills-based oral care training, with a greater emphasis on context-specific oral care curricula tailored to patients with stroke.

Regarding opportunity, the absence of standardized protocols (e.g., for documentation and assessment) made HCPs perceive inconsistent practices. This highlights a gap in current stroke oral care guidelines, which often lack detailed implementation guidance [15]. Future efforts should focus on developing evidence-based oral care protocols that include clear specifications for frequency of care, documentation standards, and risk assessment procedures, and integrate these into electronic health records.

Shortages of oral care tools were reported across various economic settings, corroborating earlier findings [42, 43]. In contrast, challenges in accessing dental services were more prominent in high-income countries. For example, some HCPs reported relying on advising individuals to “see their dentist” as a referral pathway [40], underscoring a critical disconnect between medical and dental care systems. In Australia, some nurses were unaware of available dental referral services, which may reflect the lack of national strategies for integrating oral health into stroke management [22]. To address this, dental services should be incorporated into stroke units, dentists should be included in multidisciplinary teams, and all HCPs should be informed about available dental resources and referral pathways [24, 44, 45].

Reasons for refusal and resistance to oral care among patients with stroke are multifaceted. Beyond common physical and psychological barriers, socioeconomic factors also influenced willingness to receive care, aligning with previous quantitative studies [46]. However, this review did not identify which specific dental services may exacerbate financial burdens, an area that could be further explored [47]. Furthermore, variations in personal preferences and limited understanding of oral care among patients with stroke further contributed to non-compliance, consistent with existing literature [46]. Such resistance may heighten the technical challenges of oral care, reduce HCP confidence, and promote avoidance behaviors, thereby reinforcing the low priority of oral hygiene. Future interventions should therefore emphasize person-centered approaches, such as co-designing oral care tools and providing free oral care kits to economically disadvantaged individuals.

The interpersonal relationship between patients and HCPs facilitates patient engagement [48], influenced primarily by trust and communication [49]. This is consistent with therapists’ expressions in this study that limited contact and communication with patients with stroke hindered the delivery of oral care. Existing research has largely explored communication and relationship-building between HCPs and stroke patients with dysarthria [50, 51]. Future research should further investigate the impact of interpersonal relationships on the implementation of oral care by HCPs in stroke settings.

Regarding motivation, role expectation conflict among HCPs in oral care emerged as a significant yet underreported barrier in earlier reviews [20, 22]. This finding aligns with dimensions of role theory [52]. Existing oral care guidelines lack detailed implementation advice and clarification on the roles of oral care providers [15]. Consequently, future implementation projects aimed at enhancing oral care for individuals with stroke should prioritize establishing explicit role definitions for HCPs [37].

Limitation

This review has several limitations. First, only English-language publications were included. Most studies originated from high-income countries (e.g., the UK and Australia), and the setting was limited to hospitals. Barriers to oral care in resource-limited settings and communities may differ significantly from those in high-income countries and hospital settings, potentially involving more pronounced resource shortages and less developed policy frameworks. Second, the inherent nature of qualitative research and the limited number of included articles may restrict the generalizability of the findings. Therefore, further validation across diverse regions, particularly in low-income countries, is warranted. Moreover, this study identified barriers primarily concentrated within the opportunity and motivation components of the COM-B model, with the capability component mainly addressing physical capability, while psychological capability, such as memory, attention, and decision-making processes, received less attention. This imbalance may be attributed to the difficulty in capturing the intrinsic mechanisms underlying the barriers experienced by HCPs during oral care provision through interview-based methods. Future research should continue to explore these underexplored areas. Furthermore, some barriers may span multiple components. To avoid overlap, the research team focused more on explicit meanings, while implicit meanings were not systematically categorized. In the future, more refined methods could be adopted to comprehensively understand these barrier factors. Finally, this study focused primarily on barriers; future reviews should incorporate the perspectives of patients with stroke, family caregivers, and other informal caregivers to achieve a holistic understanding of both barriers and facilitators to oral care.

Conclusion

Based on the COM-B model and the TDF, this review systematically identified multiple barrier factors faced by multidisciplinary HCPs when providing oral care to patients with stroke. The findings highlight that a one-size-fits-all approach is unlikely to be effective; instead, multifaceted interventions are essential to promote oral care in this population.

Supplementary Information

Supplementary Material 1. (13.9KB, docx)

Acknowledgements

The authors have nothing to report.

Authors’ contributions

Conceptualization (CZ, XRL); Methodology (WGZ, WX); Data curation (WHZ, XRL, WGX, SYH, SLL); Project administration (CZ); Investigation (XRL, WHZ); Writing – original draft (XRL); Writing – review and editing (WHZ, WGX, SLL, CZ).

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

Data available upon request from the authors.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Supplementary Materials

Supplementary Material 1. (13.9KB, docx)

Data Availability Statement

Data available upon request from the authors.

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