Evaluation of Oral Hygiene Status in Patients with Hemorrhagic and Ischemic Stroke

Abstract

Background:

Stroke can broadly be categorized into ischemic or hemorrhagic. Ischemic stroke accounts for 85% of cerebrovascular accidents (CVAs), whereas hemorrhagic stroke accounts for 15% of CVAs. Stroke is broadly associated with loss of sensation or unilateral paralysis of orofacial structures.

Objectives:

The present study was conducted to evaluate the prevalence of various oral features in patients with ischemic and hemorrhagic stroke.

Materials and Methods:

One hundred patients diagnosed with stroke admitted in the intensive care unit were included in the study. The evaluation of oral manifestations and their prevalence was done by a well-experienced oral medicine expert deputed in the dental department of the hospital. A single examiner performed all oral evaluations.

Results:

The mean and median for the age were 60.8 and 59. Sixty of 100 patients were male, whereas 38 were female. Forty patients had hemorrhagic stroke, whereas 60 had ischemic stroke. Senenty-eight patients of 100 had features of periodontitis, 90 of 100 patients presented with halitosis, 79 presented with caries, 83 patients had positive signs of tongue hypermobility, and 75 patients had dysphagia.

Conclusion:

Oral hygiene is the most neglected aspect during rehabilitation in stroke patients. It is critical for stroke patients to receive thorough oral care, as it can prevent other systemic ailments and potentially life-threatening complications like aspiration pneumonia.

INTRODUCTION

A stroke may be referred to as a cerebrovascular accident (CVA), which is described as an acute compromise of the cerebral perfusion or vascularity.[1] The occurrence increases strikingly with advancing age, rising twofold for a particular period of age.[2] Stroke can broadly be categorized into ischemic or hemorrhagic. Ischemic stroke accounts for 85% of CVAs, whereas hemorrhagic stroke accounts for 15% of CVAs.[3,4]

It has been reported that males are at a higher risk of developing stroke, but they are associated with 30% higher chances of survival.[5] Hemorrhagic stroke may be associated with uncontrolled hypertension, cerebral amyloid angiopathy, aneurysms, arteriovenous or cavernous malformations, capillary telangiectasia, venous angiomas, and vasculitis, etc.[6]

Clinical presentation

The signs and symptoms of strokes are like contralateral hemiparesis (incomplete paralysis affecting one side of the body), facial paralysis, and sensory loss in the face and upper extremity. Additional symptoms comprise dysarthria (imperfect articulation of speech), neglect, and aphasia (loss of comprehending spoken or written language). Patients with cerebellar infarction present with ataxia, nausea, vomiting, headache, dysarthria, and vertigo. A lacunar infarction is associated with sensorimotor deficit or ataxia with hemiparesis.[7,8,9]

Dental caries and halitosis as a result of inadequate oral hygiene maintenance due to xerostomia as a side effect of drugs used in the management of stroke can be cariogenic.[10,11] Dysphagia affects >50% of stroke survivors. Majority of the patients regain the normal swallowing function within a week's time; however, 11%–13% of the patients regain the normal function in 6 months.[12]

The current study was conducted to evaluate the prevalence of various oral features in patients with ischemic and hemorrhagic stroke.

MATERIALS AND METHODS

One hundred patients diagnosed with stroke admitted in the intensive care unit were subjected to magnetic resonance imaging and contrast-enhanced computed tomography imaging to diagnose the type of stroke. The evaluation of oral manifestations and their prevalence was done by a well-experienced oral medicine expert deputed in the dental department of the hospital. A single examiner performed all oral evaluations. All procedures performed in this study were in accordance with the ethical standards of the university foundation. Informed consent was obtained from all patients or the accompanying relatives. All the data were summarized and evaluated by ANOVA SPSS 21.0 Armonk [2012]. Standard deviation and significance level were calculated (P < 0.005).

RESULTS

One hundred patients included were between 37 and 89 years of age. The mean and median for the age were 60.8 and 59. Sixty-two of 100 patients were male, whereas 38 were female. Forty patients had a hemorrhagic stroke, whereas 60 had an ischemic stroke. Data analysis of oral symptoms in stroke was performed, as shown in Table 1. Data analysis of oral symptoms in hemorrhagic stroke was performed, as shown in Table 2. Table 3 demonstrates data Analysis of oral symptoms in ischemic stroke.

Table 1.

Data analysis of oral symptoms in stroke

Statistical test	Periodontitis	Halitosis	Caries	Tongue hypermobility	Dysphagia
Mean	0.82	0.90	0.79	0.82	0.75
Median	1	1	1	1	1
Maxima	1	1	1	1	1
Minima	0	0	0	0	0
Variance	0.1476	0.091	0.168	0.1476	0.189
SD	0.3841	0.3013	0.02822	0.3841	0.0357
P	0.998	0.9984	1.0	0.998	0.9125

SD: Standard deviation

Table 2.

Data analysis of oral symptoms in hemorrhagic stroke

Age group	Statistical test	Periodontitis	Halitosis	Caries	Tongue hypermobility	Dysphagia
30–40	Mean	5.5	6.167	5.33	5.0	5.5
41–50	Median	3.5	3.5	2.5	3.5	4.0
51–60	Maxima	14	17	17	14	14
61–70	Minima	1	2	1	0	1
71–80	Variance	25.9	35.767	39.467	31.2	24.7
81–90	SD	5.08	5.98	6.28	5.58	4.96
P	0.9975

SD: Standard deviation

Table 3.

Data analysis of oral symptoms in ischemic stroke

Age group	Statistical test	Periodontitis	Halitosis	Caries	Tongue hypermobility	Dysphagia
30–40	Mean	8.167	8.83	8.0	8.667	7.0
41–50	Median	7.0	7.0	6.0	6.5	5.0
51–60	Maxima	16	18	17	17	15
61–70	Minima	2	2	2	2	0
71–80	Variance	37.76	44.96	42.40	45.86	37.6
81–90	SD	6.14	6.70	6.50	6.77	6.13
P	0.9892

SD: Standard deviation

DISCUSSION

Our study also had a majority of cases with ischemic stroke (n = 60). Our results were in concordance with the study conducted by Koolaee et al 2018 who investigated two-third patients were marked with ischemic stroke.[13]

Patients in our study were between 37 and 89 years of age, the mean was 60.8 years, and these findings were similar to the results in the one conducted by Fekadu et al.[14] Sixty-two of 100 patients in the current study were male, whereas 38 were female. These findings were contrary to the one conducted by Mary Grace et al in 2016.[15]

In our study, 78 patients of 100 had features of periodontitis. Hashemipour et al. 2013 had similar results in their study who investigated gingivitis and periodontitis as a risk factor for stroke in the Iranian population. Stroke patients are more conducive to develop periodontal disease due to inappropriate oral hygiene maintenance. This may be as a result of reduced swallowing ability and constrained tongue movement owing to weakness of the orofacial musculature which favors accumulation of plaque and bacteria.[16]

It has been reported that periodontal disease is allied to a raised echelon of inflammatory mediators such as C-reactive protein, tumor necrosis factor alpha, and interleukin-6 (IL) in blood flow. The elevated levels of these inflammatory markers are linked to systemic diseases, such as rheumatoid arthritis, cardiovascular diseases, dementia, and Alzheimer's Disease.[17] Numerous studies have reported that periodontal disease can predispose the patient to develop cerebrovascular disease. The raised levels of inflammatory markers such as C-Reactive protein, IL-6, and lipoprotein-associated phospholipase A2 are considered as indicators of increase of stroke risk. Hence, a thorough oral care must be carried out, thereby avoiding any periodontal changes that may act as a predisposing factor to diseases, such as stroke. A periodontal therapy may lower the levels of oral bacteria and inflammatory markers, which may influence systemic disorders.[18]

Ninety of 100 patients presented with halitosis. Halitosis or fetor oris is an unpleasant odor originating from the oral cavity, often causing anxiety and psychosocial embarrassment. Loss of sensation affects up to 78% of stroke patients resulting in stasis of saliva and food in the oral cavity. Kim J in 2006 reported the action of bacteria on the pooled food causes its breakdown into sulfur compounds. Furthermore, the reduced tongue pressure and altered movements result in the pooling of food in the oral sulci which may predispose the patient to develop halitosis.[19]

Eighty-three patients had positive signs of tongue hypermobility. Tongue hypermobility may be attributed to the weakness of orofacial musculature, making the movement involuntary. Seventy-five patients had dysphagia. Majority of these patients regain their swallowing function within 7 days, whereas 11%–13% reflect symptoms of dysphagia even after 6 months. Pradeep AR in 2010[18] and H. T. Kim in 2018[20] showed similar results. The most gravid complication associated with dysphagia is aspiration pneumonia. The center for regulating the swallowing function is located in the nucleus tractus solitarius, the reticular formation, and nucleus ambiguus in the rostral and ventrolateral medulla. Any lesion in these areas regardless of the size may cause paralysis or weakening the pharynx, larynx, and the soft palate and initiates dysphagia. Fagundes NCF also suggested similar results in his study[21]

Regular dental visits are mandatory for these patients. The caregivers of these patients should be delivered a systematic oral health training to help them to improve their oral hygiene.

CONCLUSION

Oral hygiene is the most neglected aspect during rehabilitation in stroke patients. It is critical for stroke patients to receive thorough oral care as it can prevent other systemic ailments and potentially life-threatening complications like aspiration pneumonia.

The limitations of the study included a smaller sample size; the current study gathered no information on the nature of food consumed and the cognitive functions of the patient. No information was collected on whether the patients were functionally dependent or independent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.