Integrated oral health care for stroke patients - a scoping review

Oral Health in Patients Hospitalized Because of Ischemic Stroke

Background/Objectives: Maintenance of good oral health is relevant to overall health and quality of life. Results of many analyses showed that stroke patients had worse oral health than the control population. The aim of this study was a clinical assessment of oral condition in post-stroke patients and a healthy population. Methods: Oral health was assessed in stroke patients on the first day of ischemic stroke, and in a control group of healthy subjects. The number of teeth, the presence of active carious foci, fillings, and prosthetic restorations were evaluated. To assess oral hygiene, the Approximal Plaque Index (API) was used. In periodontal examinations, the presence of dental deposits, the depth of the existing periodontal pockets, tooth mobility, and the Sulcus Bleeding Index (SBI) during probing were assessed. Results: Significantly higher mean values of Decayed Teeth (DT), Missing Teeth (MT), and Decayed, Missing, and Filled Teeth (DMFT) indices were recorded in the study group. The incidence of dental caries, API, and SBI was also significantly higher in the study group. The study and control groups did not differ significantly in the average number of pockets 3 mm deep and deeper and in the frequency of having prosthetic restorations. Conclusions: Oral health and the level of oral hygiene in patients hospitalized because of ischemic stroke, in comparison with that in a healthy population, is not satisfactory. Active interdisciplinary collaboration between various medical specialists in the therapy of patients with general illnesses, including stroke, is strongly recommended.

Aspiration pneumonia in nursing literature-a mapping review

Introduction

Aspiration pneumonia (AP) is an infection of the lungs caused by inhalation of material. The reported incidences vary across literature and clinical populations and is associated with high morbidity and mortality. Management of AP is best carried out by a multidisciplinary team.

Methods

This aim of this review was to collate and describe the available evidence on AP to develop a greater understanding of the concept of AP as it is represented in the nursing literature. As a collaborative team, we undertook the six stages of a systematic mapping review. We searched for the term aspiration pneumonia in 200 peer reviewed nursing journals across 10 databases, over a ten-year period (2013-2023).

Results

In this review, 293 papers were coded. Dysphagia, oral health and tube feeding emerged as the most frequent risk factors for AP, and the most reported factors for preventing this condition. Mortality was the most commonly described consequence of AP, followed by hospitalisations and morbidity. Multiple management approaches were reported including dysphagia assessment, risk evaluation, oral care and texture modification of food and fluids. The role of nurses and interprofessional collaborations were described.

Discussion

Despite limited evidence related to the topic of AP in the nursing literature, the complexity of the causes, prevention, management and consequences of AP emerged. Certain factors, such as dysphagia, oral health, and tube feeding, were described under prevention, cause and management of AP. The importance of multidisciplinary approach in the management and prevention of AP was presented.

Oral Health Care Among Women in Perimenopause or Menopause: An Integrative Review

INTRODUCTION

Women in menopause are at a higher risk of developing oral health problems, affecting their overall quality of life. Several studies have identified the role of health care providers in addressing women's oral health needs across various phases of their lives, yet a review in the area of perimenopause and menopause has not been undertaken. Therefore, the aim of this review was to explore current evidence regarding the oral health knowledge, attitudes, and practices of women in perimenopause or menopause and their health care providers. Additionally, guidelines and recommendations to inform strategies for oral health promotion are included.

METHODS

A systematic search was carried out across 5 databases. Inclusion criteria included articles published in English that examined at least one study outcome: oral health knowledge, attitudes, and practices of either women in perimenopause or menopause or of health care providers or guidelines around oral health care. Qualitative, quantitative, mixed-methods, and experimental studies with survey components were included with no restrictions on publication period, quality, or setting.

RESULTS

A total of 12 articles met the inclusion criteria, with a majority being of poor quality and mostly from low-income and middle-income countries. Overall findings indicated that there was a lack of knowledge and limited practices in maintaining oral hygiene and visiting the dentist among women in perimenopause or menopause. Health care providers exhibited poor attitudes in advising the importance of periodic dental check-ups and informing oral health changes during this period. There were also insufficient guidelines to adopt care for women and guide health care providers in their practice.

DISCUSSION

Women in perimenopause or menopause have limited oral health knowledge and unmet oral health needs. Appropriate guidelines and supportive strategies are required to assist health care providers in providing comprehensive care and encouragement to women in perimenopause or menopause to improve their oral health.

Oral Health Differences Between Middle-Aged and Older Adults in South Korea

INTRODUCTION AND AIMS

The oral health characteristics of middle-aged and older adults exhibit variations. This study identifies the various factors associated with oral health among middle-aged and older adults through a subgroup analysis by age group of data representative of the South Korean population.

METHODS

We examined influencing factors: demographic, socioeconomic, dental, physical attributes, psychological, and mental attributes. Oral health was assessed using the Geriatric Oral Health Assessment Index. The participants were divided into two groups: those under 65 years of age (middle-aged) and those over 65 years of age (older adults). We used multiple linear regression analysis and dominance analysis to determine the dominant factors associated with oral health.

RESULTS

A total of 6369 participants were aged 69.2 ± 9.8 years on average, and 57.5% were women. Dominance analysis revealed that lower educational levels and activity difficulty caused by diseases were significantly associated with both groups. Moreover, depressive symptoms were the foremost adverse factor linked to oral health in the middle-aged (P < .001, standardized beta [β] = -4.30, general dominance index [GDI] = 19.00) and older (P < .001, β = -0.30, GDI = 10.70) adults. The number of teeth exhibited the most positive association with oral health in both middle-aged (P < .001, β = 0.20, GDI = 5.30) and older (P < .001, β = 0.23, GDI = 7.40) adults. However, cognitive function, dental visits, body mass index, severe pain, functional limitations, and cognitive function exhibited distinct patterns between the age groups.

CONCLUSION

Depressive symptoms and the number of teeth significantly influence oral health in middle-aged and older adults, though the impact varies by age. These findings stress the importance of tailored strategies considering age-specific attributes for effective oral health improvement.

CLINICAL RELEVANCE

Enhancing oral health requires healthcare providers to prioritize monitoring age-specific risk factors. Further, educational plans should highlight the importance of preventive oral care and regular dental visits.

Oral health knowledge, attitudes and practices of dietitians in Australia: A national survey

AIM

Dietitians are a well-placed profession to be providing pre-emptive oral health promotion. Despite recommendations that oral health promotion should be routinely part of dietetic practice, there is limited data informing the current practices of clinical dietitians in this area across Australia. Hence, the aim of this study was to investigate the knowledge and practices of Australian dietitians and oral health promotion.

METHODS

A cross-sectional survey was undertaken involving registered clinical dietitians in Australia using purposive and snowballing sampling (social media/dietetic organisations/public databases). Data were analysed using descriptive and inferential statistics.

RESULTS

A total of 149 dietitians participated in the national survey. Overall, dietitians were knowledgeable about oral health risk factors and preventative measures across general health domains. Majority of dietitians agreed that oral health can affect nutrition interventions (95.5%) and dietitians should be discussing oral health (88.0%). However, nearly half were not confident in providing counselling or education and felt that undergraduate training for oral health promotion was inadequate (78.2%). A small proportion (6.0%) of dietitians were already providing oral health promotion regularly. Key barriers included a lack of clear guidelines for practice, limited training opportunities and indistinct referral pathways.

CONCLUSION

Dietitians have acknowledged that oral health promotion should be incorporated into their practice. However, they are challenged by a lack of resources and training to support this in clinical practice. SO WHAT?: Capacity building dietitians to promote oral health allows opportunity for improvement in the oral health, nutritional status and quality of life of priority population groups.

Oral health decline in patients after stroke: a qualitative study

Introduction To develop and implement effective oral care interventions for patients after stroke, there is a need to understand the causes behind the decline in their oral health. This qualitative study was, therefore, undertaken to explore experiences and views of health service providers about the causes of oral health decline in this group of patients.Methods A purposively selected sample of healthcare service providers who work in two NHS Trusts in the North of England were interviewed utilising a semi-structured interview technique. Interviews were conducted with the assistance of a topic guide and continued until data saturation (n = 30) was reached. The constant comparative approach was used to analyse the data.Results Two major factors, perceived by the participants, were thought to cause oral health decline in patients after stroke. Post-stroke neurological deficits resulting in oral-related functional disturbances was the first. The second was the barriers leading to difficulties in performing or receiving daily oral care. These barriers were related to the patients, their service providers, or the environment in which care is being delivered.Conclusions This study described the major factors affecting the oral health of patients after stroke, which can offer a starting point for developing effective oral care interventions for them.

Postoperative dysphagia as a predictor of functional decline and prognosis after undergoing cardiovascular surgery

AIMS

Post-extubation dysphagia (PED), an often overlooked problem, is a common and serious complication associated with mortality and major morbidity after cardiovascular surgery. Dysphagia is considered an age-related disease, and evaluating its long-term effects is a pressing issue with rapidly progressing ageing worldwide. Therefore, we examined the effect of PED on functional status and long-term cardiovascular events in patients undergoing cardiovascular surgery.

METHODS AND RESULTS

This single-centre, retrospective cohort study included 712 patients who underwent elective cardiovascular surgery and met the inclusion criteria. Patients were divided into PED and non-PED groups based on their post-operative swallowing status. The swallowing status was assessed using the Food Intake Level Scale. Functional status was evaluated as hospital-associated disability (HAD), defined as a decrease in activities of daily living after hospital discharge compared with preoperative values. The patients were subsequently followed up to detect major adverse cardiac and cerebrovascular events (MACCEs). Post-extubation dysphagia was present in 23% of the 712 patients and was independently associated with HAD (adjusted odds ratio, 2.70). Over a 3.5-year median follow-up period, MACCE occurred in 14.1% of patients. Multivariate Cox proportional hazard analysis revealed HAD to be independently associated with an increased risk of MACCE (adjusted hazard ratio, 1.85), although PED was not significantly associated with MACCE.

CONCLUSION

Post-extubation dysphagia was an independent HAD predictor, with the odds of HAD occurrence being increased by 2.7-fold due to PED. Hospital-associated disability accompanied by PED is a powerful predictor of poor prognosis. Perioperative evaluation and management of the swallowing status, and appropriate therapeutic interventions, are warranted.

Influencing factors associated with oral health among older hospitalized patients with ischemic stroke: A cross-sectional survey

Objective

To investigate the oral health status of older patients with ischemic stroke and analyze the influencing factors, providing valuable insights for developing effective oral health management strategies tailored for this population.

Methods

A cross-sectional survey was conducted from January to June 2022, selecting 350 older patients with ischemic stroke from two tertiary hospitals in Chongqing. The Barthel Index (BI), Eating Assessment Tool (EAT-10), and Oral Health Assessment Tool (OHAT) were used to assess patients' self-care ability, swallowing function, and oral health status, respectively. A self-designed questionnaire was used to collect demographic information, disease-related information, and oral health behaviors of the patients. Binary logistic regression analysis was performed to analyze related influencing factors.

Results

A total of 346 older patients with ischemic stroke were included, with 199 males and 147 females. The median total score of OHAT was 5 (total score range 0-16). Dental decay (91.7%, 278/303) and poor oral hygiene (92.2%, 319/346) were the main oral health problems in this population. Binary logistic regression analysis showed that sex, hyperlipidemia, stroke severity, stroke events, oral health behaviors, and care dependency were influencing factors for the oral health of this population (P < 0.05).

Conclusion

The study revealed that healthcare professionals should strengthen the oral health assessment of older patients with ischemic stroke and implement individualized health education and management measures based on the characteristics of high-risk groups to promote their oral health.

Differences in the oral health status in hospitalised stroke patients according to swallowing function: A cross-sectional study

BACKGROUND

Dysphagia is one of the common complications caused by stroke, leading to poor oral health. Oral health is often neglected after stroke by clinical care providers and the patients. Identifying the status of oral health in hospitalised stroke patients with swallowing disorders will facilitate the attention of clinical care providers.

AIM

To investigate the differences in the oral health status between hospitalised post-stroke patients with dysphagia and non-dysphagia.

DESIGN

A cross-sectional study.

METHODS

A purposive sampling method was used to recruit participants. Participants included hospitalised post-stroke patients with dysphagia and without dysphagia. Stroke patients were recruited from the Department of Neurology, Guizhou Provincial People's Hospital in China. A total of 120 stroke patients completed the survey. The data collected included their demographics, the scores on the Oral Health Assessment Tool (OHAT), Geriatric Oral Health Assessment Index (GOHAI), and the Eating Assessment Tool-10 (EAT-10). The study was compliant with the STROBE checklist.

RESULTS

The average age of the dysphagia group was 67 (64~76) vs the participants without dysphagia group 67 (65~76), (p = .610). The mean standard deviation (SD) OHAT score of participants with dysphagia was 5.28 (2.33) compared to participants without dysphagia 8.89 (3.07), (p < .05). This result indicates post-stroke dysphagia (PSD) patients had worse oral health than stroke patients without dysphagia. Binary logistic regression analysis showed that oral health status was the independent influencing factor of swallowing function (p < .01).

CONCLUSION

The participants with dysphagia had worse oral health status compared to those without dysphagia, illustrating the critical importance of improving attention to oral health management in patients with post-stroke swallowing disorders.

RELEVANCE TO CLINICAL PRACTICE

Oral health was often omitted when comparing to other functional impairments resulting from stroke. Health caregivers of post-stroke patients with dysphagia should be aware of the importance of evaluating patient's oral condition and implementing oral care.

Exploring oral care practices, barriers, and facilitators in an inpatient stroke unit: a thematic analysis

PURPOSE

Oral care is essential to support the health and rehabilitation of stroke survivors but is often performed poorly in the inpatient setting. This article examines the current practices, barriers and facilitators to oral care on an Australian stroke unit to inform future knowledge translation interventions within this setting.

METHODS

Qualitative semi-structured interviews were conducted with nursing staff members and speech-language pathologists with experience delivering oral care to stroke survivors. Reflexive thematic analysis was used to analyse the data.

RESULTS

Three themes were developed from the data. In the first theme, participants described current oral care practices within their stroke unit and acknowledged that there is room for improvement. In the second theme, participants identified the multiple overlapping barriers to oral care delivery on the ward. Finally, the third theme explored participants' suggestions for improving oral care, including both local and organisational change.

CONCLUSIONS

This study illustrates the complexities of oral care in the inpatient stroke setting and gives voice to the perspectives of nursing and speech-language pathology staff. It is clear that future oral health interventions in this setting require a comprehensive approach to addressing barriers and should prioritise the concerns of staff delivering the care.IMPLICATIONS FOR REHABILITATIONThe delivery of good oral care post-stroke is essential, but in practice is difficult due to limited time and supplies, inadequate education, fear of harm to patient and self, and perceived low priority of the care.Speech-language pathologists are often involved in oral care, but their role is not clearly delineated, and they are not provided with formal training in oral care provision.Oral care interventions should be comprehensive, including organisational policies, clear practice guidelines, structured multi-disciplinary education, and appropriate supplies.

Patterns and predictors of dental hospitalizations in patients with acquired brain injury from pre-injury to acute and post-acute injury

BACKGROUND

Acquired brain injury (ABI) can cause long-term disability and functional impairment.

OBJECTIVE

This study aims to determine the prevalence of dental hospitalizations in an ABI cohort across different phases of injury and identify factors associated with such hospitalizations.

METHODS

The cohort comprises patients with ABI (n = 683), traumatic (n = 282) and non-traumatic (n = 401) who were admitted to a neurorehabilitation service in Western Australia between 1991 and 2016. De-identified patient data were linked to the Hospital Morbidity Data Collection. The incidence of dental hospitalizations was calculated per 1,000 person-years (PY), and associated factors were investigated using multilevel mixed-effects logistic regression.

RESULTS

Dental hospitalizations significantly increased from pre-injury (3.35/1,000PY) to acute injury (302.65, Δ+299.3) and remained elevated in the post-acute phase (23.98, Δ+20.63). Dental caries had the highest incidence rate among all diagnoses in the pre-injury and post-acute phases (0.68 and 8.93, respectively), followed by gingivitis and periodontal diseases (3.60) in the post-acute phase. Tooth extractions were performed more often than restorative and preventive treatment in the pre-and post-injury phase, p < 0.001. Dental hospitalizations were associated with the type of ABI, age at injury, remoteness, and history of pre-injury hospitalization.

CONCLUSION

Implementing comprehensive preventive dental care can reduce potentially preventable dental hospitalization among ABI patients.

Factors that influence oral hygiene care with hospitalised stroke patients: a mixed methods study

PURPOSE

Survivors of stroke experience poor oral health during and following hospitalisation. Health professionals consistently report that oral hygiene is complex. Interventions aiming to improve the delivery of oral hygiene care by health professionals rarely use a theoretically driven approach. This study reports the first phase in an intervention development and uses the action, actor, context, target, time (AACTT) framework and theoretical domains framework (TDF) to understand who needs to do what differently in the delivery of oral hygiene care with hospitalised stroke survivors.

METHOD

Mixed methods including analysis of oral health policies and clinical guidelines using the AACTT framework, focus group discussions using the TDF and audit of 60 medical records.

RESULTS

Policies and guidelines lack specificity regarding what oral hygiene care is and who should be responsible. Health professionals have low beliefs in their capabilities and experience numerous contextual barriers. More than 40% of patients had no documented evidence of oral hygiene care.

CONCLUSION

This study used a theoretically driven approach to identify barriers and enablers to health professional delivery of oral hygiene care with stroke survivors. Interventions aiming to improve clinical practice should target beliefs about capabilities, improved access to resources and detailed oral hygiene clinical guidelines.Implications for rehabilitationSurvivors of stroke experience poor oral health which can contribute to further strokes, cardiovascular disease and mortality.Health care professionals report difficulties in delivering oral hygiene care to hospitalised stroke survivors and clinical guidelines lack detail regarding oral health assessments, interventions and training.Interventions aiming to improve the delivery of oral hygiene care should target health professional beliefs about their capabilities using strategies such as behavioural practice.Resources specific to oral hygiene care for more complex patients, including suctioning toothbrushes, should be readily accessible for health professional use.Clinical guidelines and policies on oral hygiene care should include detail about training content, assessments tools and how to adapt information for patients with complex impairments.

Quantitative data collection approaches in subject-reported oral health research: a scoping review

Background

This scoping review reports on studies that collect survey data using quantitative research to measure self-reported oral health status outcome measures. The objective of this review is to categorize measures used to evaluate self-reported oral health status and oral health quality of life used in surveys of general populations.

Methods

The review is guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) with the search on four online bibliographic databases. The criteria include (1) peer-reviewed articles, (2) papers published between 2011 and 2021, (3) only studies using quantitative methods, and (4) containing outcome measures of self-assessed oral health status, and/or oral health-related quality of life. All survey data collection methods are assessed and papers whose methods employ newer technological approaches are also identified.

Results

Of the 2981 unduplicated papers, 239 meet the eligibility criteria. Half of the papers use impact scores such as the OHIP-14; 10% use functional measures, such as the GOHAI, and 26% use two or more measures while 8% use rating scales of oral health status. The review identifies four data collection methods: in-person, mail-in, Internet-based, and telephone surveys. Most (86%) employ in-person surveys, and 39% are conducted in Asia-Pacific and Middle East countries with 8% in North America. Sixty-six percent of the studies recruit participants directly from clinics and schools, where the surveys were carried out. The top three sampling methods are convenience sampling (52%), simple random sampling (12%), and stratified sampling (12%). Among the four data collection methods, in-person surveys have the highest response rate (91%), while the lowest response rate occurs in Internet-based surveys (37%). Telephone surveys are used to cover a wider population compared to other data collection methods. There are two noteworthy approaches: 1) sample selection where researchers employ different platforms to access subjects, and 2) mode of interaction with subjects, with the use of computers to collect self-reported data.

Conclusion

The study provides an assessment of oral health outcome measures, including subject-reported oral health status and notes newly emerging computer technological approaches recently used in surveys conducted on general populations. These newer applications, though rarely used, hold promise for both researchers and the various populations that use or need oral health care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02399-5.

Myofunctional device use in oral care and swallowing: a protocol for a feasibility study in an aged care population

Background

Poor oral health is a known predictor of aspiration pneumonia in vulnerable populations such as the elderly and chronically ill and has been linked to systemic disease, morbidity, and mortality. Reduced oral health not only places individuals at a greater risk of aspiration pneumonia but may result in pain or poorer dentition which can impact on mastication and swallowing. Consequences of this may include reduced oral intake, malnutrition, poorer health outcomes, and reduced quality of life. Few evidence-based protocols exist to manage oral care in aged care populations, and maintenance of good oral hygiene is difficult for nursing and care staff to facilitate. However, a recent literature review found that improvements in oral hygiene, oral behaviors, and swallowing, along with breathing and speech have been found to be associated with the use of myofunctional devices due to positive changes in orofacial functions such as lip seal, mastication, swallowing, and nasal breathing patterns. The primary aim of this study is to assess the feasibility of using a myofunctional device to improve oral care and swallowing function in an aged care population.

Methods/design

This project is a feasibility study that involves a 5-week intervention for oral hygiene and dysphagia for residents >65 years old in an aged care setting. Feasibility will be determined by the acceptability of the intervention, study recruitment and retention, and adherence to the intervention. Feasibility testing will also include an evaluation of clinical outcome measures, and sensitivity to detect changes in oral health and swallowing in an aged care population.

Discussion

The results of this trial will provide important information regarding the feasibility of utilizing a myofunctional device to improve oral care and dysphagia in elderly patients in an aged care facility. This knowledge will further guide and inform design of a larger trial or future research.

Trial registration

This trial was registered August 10, 2021, with the Australian New Zealand Clinical Trials Registry and allocated the ACTRN: ACTRN12621001359820.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01148-3.

Effects of Oral Health Interventions in People with Oropharyngeal Dysphagia: A Systematic Review

People with oropharyngeal dysphagia (OD) are at risk of developing aspiration pneumonia. However, there is no “best practice” for oral health interventions to improve swallowing-related outcomes, the incidence of aspiration pneumonia, and oral health in people with OD. Systematic literature searches were conducted for oral health interventions in OD in PubMed, Embase, CINAHL, and PsycINFO until July 2021. Original articles published in English and reporting pre- and post-intervention measurements were included. The methodology and reporting were guided by the PRISMA checklist. The methodological quality of the eight included studies was rated using the QualSyst critical appraisal tool. The oral health interventions in people with OD were diverse. This study shows little evidence that regular oral care and the free water protocol or oral disinfection reduced the incidence of aspiration pneumonia in people with OD. Oral cleaning, twice a day with an antibacterial toothpaste in combination with intraoral cleaning or the free water protocol, proved to be the most promising intervention to improve oral health. The effect of improved oral health status on swallowing-related outcomes could not be established. Increasing awareness of the importance of oral health and implementing practical oral care guidelines for people involved in the daily care of people with OD are recommended.

How Do Dental Clinicians Obtain Up-To-Date Patient Medical Histories? Modeling Strengths, Drawbacks, and Proposals for Improvements

Background

Access to up-to-date patient medical history is essential for dental clinicians (DCs) to avoid potential harm to patients and to improve dental treatment outcomes. The predominant approach for dental clinicians (DCs) to gather patients' medical history is through patient-reported medical histories and medical consults. However, studies reported varied concordance and reliability of patient-reported medical conditions and medication histories compared to the patient medical records and this process also places a significant burden on patients. Information technology tools/platforms such as an integrated electronic health record containing an electronic dental record module may address these issues. However, these integrated systems are expensive and technically complex and may not be easily adopted by DCs in solo and small group practice who provide the most dental care. The recent expansion of regional healthcare information exchange (HIE) provides another approach, but to date, studies on connecting DCs with HIE are very limited. Our study objectives were to model different aspects of the current approaches to identify the strengths and weaknesses, and then model the HIE approach that addresses the weaknesses and retain the strengths of current approaches. The models of current approaches identified the people, resources, organizational aspects, workflow, and areas for improvement; while models of the HIE approach identified system requirements, functions, and processes that may be shared with software developers and other stakeholders for future development.

Methods

There are three phases in this study. In Phase 1, we retrieved peer-reviewed PubMed indexed manuscripts published between January 2013 and November 2020 and extracted modeling related data from selected manuscripts. In Phase 2, we built models for the current approaches by using the Integrated DEFinition Method 0 function modeling method (IDEF0), the Unified Modeling Language (UML) Use Case Diagram, and Business Process Model and Notation (BPMN) methods. In Phase 3, we created three conceptual models for the HIE approach.

Results

From the 47 manuscripts identified, three themes emerged: 1) medical consult process following patient-reported medical history, 2) integrated electronic dental record-electronic health record (EDR-EHR), and 3) HIE. Three models were built for each of the three themes. The use case diagrams described the actions of the dental patients, DCs, medical providers and the use of information systems (EDR-EHR/HIE). The IDEF0 models presented the major functions involved. The BPMN models depicted the detailed steps of the process and showed how the patient's medical history information flowed through different steps. The strengths and weaknesses revealed by the models of the three approaches were also compared.

Conclusions

We successfully modeled the DCs' current approaches of accessing patient medical history and designed an HIE approach that addressed the current approaches' weaknesses as well as leveraged their strengths. Organizational management and end-users can use this information to decide the optimum approach to integrate dental and medical care. The illustrated models are comprehensive and can also be adopted by EHR and EDR vendors to develop a connection between dental systems and HIEs.

Best Practice Recommendations for Dysphagia Management in Stroke Patients: A Consensus from a Portuguese Expert Panel

Dysphagia is frequent after stroke, and it increases the risk of respiratory infection, dehydration and malnutrition, resulting in worse outcomes. Different clinical guidelines present recommendations for the assessment and management of dysphagia in stroke patients in a scattered way. These best practice recommendations address seven clinical questions on the assessment and management of dysphagia in stroke patients, gathering the best-updated evidence. A systematic literature review using the PICO strategy was performed. The recommendations draft was then appraised by a multidisciplinary panel of experts (nutritionists, physiatrists, speech-language pathologists and rehabilitation nurses) in a total of 3 Delphi rounds. A minimum of 80% consensus was established, and the final version offers a total of 21 recommendations for use in clinical practice for stroke patients. These clinical recommendations are an overview of the most recent evidence combined with experts’ consensus and translated into clinically relevant statements. In implementing recommendations at the local level, health professionals should identify facilitators and barriers to evidence-based practice within their contexts and determine the best strategies to address local needs. Where the change is needed, initial and continuing training on all recommendations is essential and relevant.

Effectiveness of Standard Oral Care Plan During Hospital Stay in Individuals With Brain Injury

Objective: To investigate the effectiveness of an existing standard oral care program (SOCP) and factors associated with it during hospitalization in individuals with acquired brain injury (ABI).

Material and Methods: A total of 61 individuals underwent a SOCP for 4 weeks in a longitudinal observational study. Rapidly noticeable changes in oral health were evaluated by performing plaque, calculus, bleeding on probing (BOP) and bedside oral examination (BOE) at weeks 1 and 5. Individuals' brushing habits, eating difficulties, and the onset of pneumonia were retrieved from their medical records. Association between oral-health outcomes to systemic variables were investigated through multilevel regression models.

Results: Dental plaque (P = 0.01) and total BOE score (P &lt; 0.05) decreased over time but not the proportion of dental calculus (P = 0.30), BOP (P = 0.06), and tooth brushing frequency (P = 0.06). Reduction in plaque and BOE over time were negatively associated with higher periodontitis scores at baseline (coef. −6.8; −1.0), respectively, which in turn were associated with an increased proportion of BOP (coef. ≈ 15.0). An increased proportion of calculus was associated with eating difficulties (coef. 2.3) and the onset of pneumonia (coef. 6.2).

Conclusions: Nursing care has been fundamental in improving oral health, especially reducing dental plaque and BOE scores. However, our findings indicate a need for improving the existing SOCP through academic-clinical partnerships.

Clinical Relevance: Early introduction of oral care program to brain-injured individuals is beneficial in reducing plaque accumulation and improving oral health.

Oral care practices in stroke: findings from the UK and Australia

Aims

To examine current practice, perceptions of healthcare professionals and factors affecting provision for oral care post-stroke in the UK and Australia.

Background

Poor oral care has negative health consequences for people post-stroke. Little is known about oral care practice in hospital for people post-stroke and factors affecting provision in different countries.

Design

A cross-sectional survey.

Methods

Questionnaires were mailed to stroke specialist nurses in UK and Australian hospitals providing inpatient acute or rehabilitation care post-stroke. The survey was conducted between April and November 2019. Non-respondents were contacted up to five times.

Results

Completed questionnaires were received from 150/174 (86%) hospitals in the UK, and 120/162 (74%) in Australia. A total of 52% of UK hospitals and 30% of Australian hospitals reported having a general oral care protocol, with 53% of UK and only 13% of Australian hospitals reporting using oral care assessment tools. Of those using oral care assessment tools, 50% of UK and 38% of Australian hospitals used local hospital-specific tools. Oral care assessments were undertaken on admission in 73% of UK and 57% of Australian hospitals. Staff had received oral care training in the last year in 55% of UK and 30% of Australian hospitals. Inadequate training and education on oral care for pre-registration nurses were reported by 63% of UK and 53% of Australian respondents.

Conclusion

Unacceptable variability exists in oral care practices in hospital stroke care settings. Oral care could be improved by increasing training, performing individual assessments on admission, and using standardised assessment tools and protocols to guide high quality care. The study highlights the need for incorporating staff training and the use of oral care standardised assessments and protocols in stroke care in order to improve patient outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-021-00642-y.

Evaluation and Acceptance of an Electric Toothbrush Designed for Dependent Patients

INTRODUCTION

A key barrier to standardizing evidence-based oral health protocols for highly dependent patients is the lack of validated and accepted oral health products designed specifically for use by caregivers. This study compared preferences by users of a novel electric toothbrush and a manual toothbrush in a health care setting.

METHODS

We prospectively enrolled health care providers as volunteers. Volunteer brushers completed simulated tooth brushing sessions of mock-intubated and non-intubated volunteer brushees with both toothbrushes. Volunteers rated different domains of toothbrush preference in an anonymous, optional survey.

RESULTS

A total of 133 health care providers volunteered (123 brushers [providers brushing teeth] and 10 brushees [those having their teeth brushed]). The novel electric toothbrush received significantly higher positive ratings than the standard hospital-issue manual toothbrush in all domains that we surveyed: ease of use, thoroughness, safety, shape and size of the brush head, overall cleanliness, time requirements, and efficiency (p<0.001). Importantly, due to the integrated light and suction of this electric toothbrush, brushers completed more sessions without setting down the toothbrush with the electric toothbrush than with the manual toothbrush (75.4% vs 36.4%; p<0.001).

CONCLUSIONS

Integrating a lighted electric brush with suction into the caregiver's armamentarium as an evidence-based tool is warranted and should be evaluated in terms of patient outcomes.

Structural Equation Modeling of Tongue Function and Tongue Hygiene in Acute Stroke Patients

In acute stroke patients, it is important to maintain tongue hygiene and tongue function for prognosis management. However, the direct relationship between these factors is unclear, since these are often assessed by multiple observables. In this study, we used structural equation modeling (SEM) analysis, a tool to analyze the relationship between concepts that cannot be measured directly, to analyze the relationship between tongue hygiene and tongue function. The subjects were 73 patients with acute stroke admitted to a university hospital who underwent dental intervention. Age, sex, nutritional intake method, clinical severity classification of dysphagia, number of current teeth, number of functional teeth, oral health, tongue movement, tongue coating, number of microorganisms on the tongue surface, tongue surface moisture level, and tongue pressure were measured at the first visit. SEM analysis showed that the relationship between tongue function and tongue hygiene was 0.05 between tongue function and swallowing function was 0.90, and that between tongue hygiene and swallowing function was 0.09. We found no statistical relationship between tongue function and tongue hygiene in acute stroke patients. However, it was reconfirmed that tongue function is strongly related to feeding and swallowing functions.

Impact of a learning health system on acute care and medical complications after intracerebral hemorrhage

INTRODUCTION

Patients with stroke often experience pneumonia during the acute stage after stroke onset. Oral care may be effective in reducing the risk of stroke-associated pneumonia (SAP). We aimed to determine the changes in oral care, as well as the incidence of SAP, in patients with intracerebral hemorrhage, following implementation of a learning health system in our hospital.

METHODS

We retrospectively analyzed the data of 1716 patients with intracerebral hemorrhage who were hospitalized at a single stroke center in Japan between January 2012 and December 2018. Data were stratified on the basis of three periods of evolving oral care: period A, during which conventional, empirically driven oral care was provided (n = 725); period B, during which standardized oral care was introduced, with SAP prophylaxis based on known risk factors (n = 469); and period C, during which oral care was risk-appropriate based on learning health system data (n = 522). Logistic regression analysis was performed to evaluate associations between each of the three treatment approaches and the risk of SAP.

RESULTS

Among the included patients, the mean age was 71.3 ± 13.6 years; 52.6% of patients were men. During the course of each period, the frequency of oral care within 24 hours of admission increased (P < .001), as did the adherence rate to oral care ≥3 times per day (P < .001). After adjustment for confounding factors, a change in the risk of SAP was not observed in period B; however, the risk significantly decreased in period C (odds ratio 0.61; 95% confidence interval 0.43-0.87) compared with period A. These associations were maintained for SAP diagnosed using strict clinical criteria or after exclusion of 174 patients who underwent neurosurgical treatment.

CONCLUSIONS

Risk-appropriate care informed by the use of learning health system data could improve care and potentially reduce the risk of SAP in patients with intracerebral hemorrhage in the acute stage.

Patient perceptions of oral health care following stroke: a qualitative study

BACKGROUND

Stroke is a serious cerebrovascular disease and is one of the world's leading causes of disability. Maintaining good oral health is a challenge among those hospitalised after stroke. A multidisciplinary approach to oral care involving non-dental professionals can be beneficial in improving oral health outcomes for patients. The aim of this study was to understand the perceptions of stroke survivors regarding oral healthcare across acute and rehabilitation settings.

METHODS

A descriptive qualitative approach was used. Face-to-face semi-structured interviews were conducted. A framework analysis was employed to analyse the data. Patients who had recently experienced a stroke were purposively recruited across both acute and rehabilitation settings, at two metropolitan hospitals in Sydney, Australia. In total, 11 patients were interviewed.

RESULTS

Although participants recognised the importance of oral health, few understood the link between oral and general health. Regular oral hygiene practices varied since having stroke, with a few receiving oral care assistance from nurses. Time, cost and lack of information were some barriers to accessing dental services, while supportive measures such as coordination of oral care, financial subsidy and nurse assistance were strategies proposed to support oral care practices amongst stroke survivors.

CONCLUSIONS

There is scope to improve current models of oral care in stroke. While stroke survivors understand the importance of oral care, an integrated oral health model with a multidisciplinary approach could improve health outcomes.

Is an Oral Health Status a Predictor of Functional Improvement in Ischemic Stroke Patients Undergoing Comprehensive Rehabilitation Treatment?

The study's aim was a clinical observation concerning the influence of oral health on functional status in stroke patients undergoing neurorehabilitation. This pilot cross-sectional clinical study was performed in 60 subacute phase stroke patients during 12 weeks of treatment. The program was patient-specific and consisted of neurodevelopmental treatment by a comprehensive rehabilitation team. The functional assessment was performed using the Barthel index (BI), Berg balance scale (BBS), functional independence measure (FIM), and Addenbrooke's cognitive examination III (ACE III) scales. Oral health was assessed according to World Health Organization (WHO) criteria, and it was presented using DMFT, DMFS, gingival index (GI), and plaque index (PlI). Significant improvement in many functional scales was noticed. However, important differences in most dental parameters without relevant changes in GI and PlI after the study were not observed. Reverse interdependence (p < 0.05) was shown between physical functioning (BI, FIM, or BBS) with GI and PlI results, and most dental parameters correlated with ACE III. Using multivariate regression analysis, we showed that ACE III and BI are predictive variables for DMFT, just as FIM is for DS (p < 0.05). The present research revealed that poor oral health status in patients after stroke might be associated with inpatient rehabilitation results.

Effectiveness of an individually tailored oral hygiene intervention in improving gingival health among community-dwelling adults with physical disabilities in Thailand

AIMS

Persons with physical disabilities require specific methods for sustaining good oral health. This study aimed to evaluate an individually tailored oral hygiene intervention program (IT-OHI) for improving gingival health among adults with disabilities.

METHODS AND RESULTS

A single group, quasi-experimental design with pre- and post-tests, conducted at a community club for disabled people in Thailand. This study included 145 adults with disabilities, aged 18-74 years. Trained caregivers provided IT-OHI program to all participants. Calibrated dentists assessed the gingival bleeding and dental plaque at baseline/pre-intervention (T0) and at 6 (T1) and 12 (T2) weeks post-intervention. The outcomes were analyzed using the Friedman test, Cochran's Q test, and Binary logistic regression. There were significant decreases in bleeding on probing scores (P < .001) and plaque control record scores (P < .001) throughout the study. However, considering the individual periods, values between T1 and T2 did not improve. Additionally, the IT-OHI program's protective effect was more substantial among the male participants at 12 weeks post-intervention (odds ratio = 0.094, P = .027) than among the females.

CONCLUSION

The IT-OHI program had partial effectiveness in improving gingival health and reducing dental plaque accumulation in a group of Thai people with physical disabilities; however, the long-term impact remains unclear.

Registered nurses' experiences of providing respiratory care in relation to hospital- acquired pneumonia at in-patient stroke units: a qualitative descriptive study

Objective

This study aimed to describe registered nurses’ (RNs) experiences of providing respiratory care in relation to hospital acquired pneumonia (HAP), specifically among patients with acute stroke being cared for at in-patient stroke units.

Background

One of the most common and serious respiratory complications associated with acute stroke is HAP. Respiratory care is among the fundamentals of patient care, and thus competency in this field is expected as part of nursing training. However, there is a paucity of literature detailing RNs’ experiences with respiratory care in relation to HAP, specifically among patients with acute stroke, in the context of stroke units. As such, there is a need to expand the knowledge base relating to respiratory care focusing on HAP, to assist with evidence-based nursing.

Design

A qualitative descriptive study.

Method

Eleven RNs working in four different acute stroke units in Southern Sweden participated in the current study. The data were collected through semi-structured interviews, and the transcribed interviews were analysed using inductive content analysis.

Results

Three overarching categories were identified: (1), awareness of risk assessments and risk factors for HAP (2) targeting HAP through multiple nursing care actions, and (3) challenges in providing respiratory care to patients in risk of HAP. These reflected the similarities and differences in the experiences that RNs had with providing respiratory care in relation to HAP among in-patients with acute stroke.

Conclusions

The findings from this study suggest that the RNs experience organisational challenges in providing respiratory care for HAP among patients with acute stroke. Respiratory care plays a vital role in the identification and prevention of HAP, but our findings imply that RNs’ knowledge needs to be improved, the fundamentals of nursing care need to be prioritised, and evidence-based guidelines must be implemented. RNs would also benefit from further education and support, in order to lead point-of-care nursing in multidisciplinary stroke teams.

Technology for maintaining oral care after stroke: considerations for patient-centered practice

PURPOSE

Activities of daily living including oral care may be challenging after stroke. Some stroke survivors are not able to complete oral care independently and need assistance from healthcare professionals and care partners. Poor oral hygiene may impact stroke recovery and rehabilitation possibly incurring issues such as aspiration pneumonia, malnutrition, and social isolation. The objective of this paper is to outline practical ways to apply oral care technology in daily use for stroke survivors.

MATERIALS AND METHODS

We reviewed the literature on i) stroke-related impairments impacting oral care, ii) oral hygiene dental devices, and iii) technology for oral care education.

RESULTS

Oral care activities involve integrated skills in the areas of motivation, energy, planning, body movement and sensation, and mental acuity and health. Post-stroke impairments such as fatigue, hemiparesis, and mental impairments may impact oral care activities. Technology may help survivors and caregivers overcome some barriers. Three types of technologies are available for facilitating post-stroke oral care: i) non-powered tools and adaptations; ii) powered oral care tools, and; iii) electronic aids to guide oral care activities. Particular choices should maximise patient safety and autonomy while ensuring accessibility and comfort during oral care tasks.

CONCLUSION

The available device and technologies may help substantially with the accommodations needed for post-stroke oral care, improving the oral health of stroke survivors. Good oral health confers benefit to overall health and well-being and could enhance recovery and rehabilitation outcomes. Nonetheless, more research is necessary to demonstrate the feasibility and effectiveness of technology in stroke contexts.IMPLICATIONS FOR REHABILITATIONOral care may be challenging after stroke due to patient fatigue, hemiparesis, cognitive impairments, and other impaired body functions.Poor oral hygiene may impact stroke recovery and rehabilitation due to risk of aspiration pneumonia, malnutrition, and social isolation.Powered oral care tools, non-powered tools, and adaptations to non-powered tools are some of the technology available to help overcome post-stroke barriers for oral care.Computer programs and online resources for education and guidance for oral care activities may help improve recommendation uptake and compliance.

Guideline Recommendations for Oral Care After Acquired Brain Injury: Protocol for a Systematic Review

BACKGROUND

Oral care is important to prevent buccal and systemic infections after an acquired brain injury (ABI). Despite recent advancements in the development of ABI clinical practice guidelines, recommendations for specific clinical processes and actions to attain adequate oral care often lack information.

OBJECTIVE

This systematic review will (1) identify relevant ABI clinical practice guidelines and (2) appraise the oral care recommendations existing in the selected guidelines.

METHODS

A search strategy was developed based on a recent systematic review of clinical practice guidelines for ABI. The protocol includes a search of MEDLINE, EMBASE, and DynaMed Plus databases, as well as organizational and best-practice websites and reference lists of accepted guidelines. Search terms will include medical subject headings and user-defined terms. Guideline appraisal will involve the Appraisal of Guidelines for Research and Evaluation II ratings, followed by a descriptive synopsis for oral care recommendations according to the National Health and Medical Research Council evidence levels.

RESULTS

This project started in April 2019, when we developed the search strategy. The preliminary search of databases and websites yielded 863 and 787 citations, respectively, for a total of 1650 citations. Data collection will start in August 2020 and we expect to begin disseminating the results in May 2021.

CONCLUSIONS

Nursing staff may not have detailed recommendations on how to provide oral care for neurologically impaired patients. The findings of this review will explore the evidence for oral care in existing guidelines and improve outcomes for patients with ABI. We expect to provide adequate orientations to clinicians, inform policy and guidelines for best practices, and contribute to future directions for research in the ABI realm.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/17249.

Comparison of perceptions, attitudes and performance regarding collaborative oral health care among health-care workers

OBJECTIVE

Collaborative oral health care among health-care workers (HCWs) is important to prevent oral and systemic diseases. The purpose of this study was to investigate the perceptions, attitudes and performance of HCWs regarding collaborative oral health care and to compare them among HCWs.

METHOD

The subjects were dentists (DTs), dental hygienists (DHs), hospital nurses (HNs), speech-language-hearing therapists (STs) and certified care workers (CCWs) in Fukuoka Prefecture, Japan. DTs were members of the Fukuoka Dental Association, and DHs worked in dental clinics. HNs worked in hospitals without dental departments. STs and CCWs were members of professional associations. Data were collected by a mail survey. The chi-square test and Kruskal-Wallis test were used to compare the data among HCWs.

RESULTS

A total of 119 DTs, 91 DHs, 229 HNs, 119 STs and 121 CCWs participated in this study. The total response rate was 20.6%. There were significant differences in perceptions of what should be performed as part of oral health care among HCWs. Only 20%-60% of HCWs performed collaborative oral health care, while more than 75% were willing to perform such care. Levels of collaborative oral health care with other types of professionals and positive willingness to perform such care were lower among HNs than among the other HCWs.

CONCLUSIONS

It is suggested that oral health professionals should recognise the presence of differences in the perceptions, attitudes and performance among other types of HCW and try to improve these to promote interprofessional collaboration of oral health care in hospitals.

Inclusive Oral Healthcare for a better Future Together

Oral health is a critical component to overall quality of life. Recommendations and guidelines for oral health continue to evolve while remaining underutilized worldwide. Still, oral healthcare parity and equity are achievable. This public health priority must be supported with stronger research, service delivery must be equitable and transparent, and the impact of oral healthcare must be fully understood. Data, surveillance, evidence and translation must be improved for oral health specialties as well as for greater global governance. Further, interdisciplinary coordination between orthodontic, dentistry, medical, biotechnology and research organizations must be prioritized. With dedication and consistent approach, oral healthcare can achieve the best outcomes for quality of life and cost effective public health.

Oral Health Knowledge Level of Nursing Staff Working in Semi-Intensive Heart Failure Units

PURPOSE

Critical care units, such as heart failure units, house inpatients with a compromised general health status that requires rigorous prevention of further complications. Oral health infections that gain access through the bloodstream or airway might represent such potential complications (eg, endocarditis pneumonia). Avoiding these critical occurrences requires that adequate oral health care be provided by nursing personnel. Here we assessed the knowledge of oral health care practices by nurses working in three Italian heart failure units in Umbria, Italy.

DESIGN

This was a cross-sectional study.

METHODS

Forty-four nurses were interviewed using a six-item modified Adams' questionnaire on the topic of oral health care. A multidisciplinary panel of experts established the criteria for answer correctness based on the most relevant dentistry literature evidence and judged each reply. The expected percentage of correctly replying nurses was 75%, and significant differences from this expected probability were calculated with one-sided binomial probability tests. Cronbach's α method was used to establish the questionnaire's internal consistency (reliability).

RESULTS

For five out of six questionnaire items, the percentage of nurses who correctly answered was significantly lower than the expected value of probability. Lack of knowledge was found for usefulness of checking the patients' mouths (p=0.003), the most relevant lesions affecting the mouth (p=0.0001), the tools/solutions for cleaning the mouth and dentures (p= 0.0416), and drugs that affect the mouth and their side effects (p<0.0001).

CONCLUSION

In this study, few nurses working in heart failure units showed both an adequate willingness to check inpatients and a good knowledge of oral health care (significantly lower than the expected 75%). Further studies that use validated questionnaires and include more participants should be conducted to confirm and elaborate on our preliminary data.

Oral Management in Rehabilitation Medicine: Oral Frailty, Oral Sarcopenia, and Hospital-Associated Oral Problems

Oral health is a crucial but often neglected aspect of rehabilitation medicine. Approximately 71% of hospitalized rehabilitation patients and 91% of hospitalized acute care patients have impaired oral health. Poor oral condition in hospitalized patients can be attributed to factors such as age, physical dependency, cognitive decline, malnutrition, low skeletal muscle mass and strength, and multimorbidity. Another major factor is a lack of knowledge and interest in oral problems among health care workers. Recently, new concepts have been proposed, such as oral frailty, oral sarcopenia, and hospital-associated oral problems. Oral frailty, the accumulation of a slightly poor status of oral conditions and function, strongly predicts physical frailty, dysphagia, malnutrition, need for long-term care, and mortality in community-dwelling older adults. Oral sarcopenia refers to sarcopenia associated with oral conditions and function, although its definition has not yet been fully discussed. Hospital-associated oral problems are caused by disease, disease treatment, surgery, endotracheal intubation, poor self-care abilities, lack of care by medical staff, drugs, and iatrogenic factors during hospitalization. Furthermore, oral problems have negative impacts on rehabilitation outcomes, which include functional recovery, length of hospital stay, discharge home, and in-hospital mortality. Oral health management provided by dental hygienists improves not only oral status and function, swallowing function, and nutritional status but also activities of daily living, discharge home, and in-hospital mortality in post-acute rehabilitation. Oral rehabilitation, promotion, education, and medical-dental collaboration can be effective interventions for oral problems and therefore are necessary to improve rehabilitation outcomes.

Periodontitis As A Risk Factor For Stroke: A Systematic Review And Meta-Analysis

This systematic review and meta-analysis investigate the association between periodontitis and stroke. This review followed the methods established by the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Searches were conducted in five databases and two sources of grey literature. After the selection of the articles, a risk of bias evaluation was performed. Three meta-analyzes were performed: Assessing the overall association between stroke and periodontitis in case–control studies; Ischemic stroke and periodontitis in case–control studies; The association between stroke and periodontitis in cohort studies. Heterogeneity was assessed using the I² index and the odds ratio was also calculated (p < 0.05). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) was applied to evaluate the level of evidence. 2193 potentially relevant studies were identified, with 10 studies included in qualitative and quantitative analysis. All the articles were considered with low risk of bias and a low level of certainty. The results demonstrated a positive association between both disorders and increased risk for stroke among cohort studies (RR 1.88 [1.55, 2.29], p<0.00001, I²=0%) and for ischemic stroke events in case–control studies (RR 2.72 [2.00, 3.71], p<0.00001, I²= 4%). Periodontitis may represent a risk factor for stroke, especially in ischemic events. However, new studies with a robust design are necessary for a reliable conclusion.

Exploring nursing and allied health perspectives of quality oral care after stroke: A qualitative study

BACKGROUND

Maintaining good oral health remains a challenge among those hospitalised after stroke. Stroke nurses and allied health clinicians have a potential role in providing oral care, but no studies in Australia to date have explored their perceptions and needs.

AIMS

To explore the perspectives of nursing and allied health stroke clinicians regarding oral care for stroke patients across acute care and stroke rehabilitation settings.

METHODS

This study followed an exploratory qualitative design, using a constructivist approach. Participants from two metropolitan public hospitals were purposively recruited to participate in focus groups. Data was thematically analysed.

RESULTS

Twenty-one clinicians participated. Clinicians' knowledge and practices relating to oral healthcare for stroke patients were inadequate. Most staff felt they did not have adequate knowledge, resources and training to administer oral care in this setting and proposed enhancing education of stroke clinicians, patients and informal caregivers, as well as improving quality point of care resources. There was overall support for the integrated dental care after stroke model of care.

DISCUSSION

This study revealed many gaps in current care and highlighted areas for improvement. Patients and their caregivers needed to be actively engaged as partners to improve oral healthcare within acute and rehabilitation stroke settings.

CONCLUSION

This study provided insight into nurses' and allied health stroke clinicians' current knowledge and practices of oral care in various stroke settings. The findings from this study will inform development of a model of care to train stroke nurses in providing oral care.

Oral health in patients with stroke: a meta-analysis of comparative studies

Objective: This meta-analysis systematically analyzed and compared oral health between stroke patients and controls.Data source: The electronic databases of PubMed, EMBASE, PsycINFO, Medline and Web of Science were independently searched by two authors from their inception to 14 June 2018.Study selection: Eleven studies comparing oral health between stroke patients (n = 1,742) and controls (n = 1,193) were analyzed.Data extraction: The full texts of the 11 studies were independently reviewed. Data on oral health were independently extracted by two authors.Data synthesis: Mean differences (MD) and 95% confidence intervals (CI) were calculated and synthesized using fixed or random-effects models, as appropriate. Compared to controls, stroke patients had poorer oral health: they had more Dental Caries (5 studies; MD = 2.89, 95% CI: 0.91-4.88, p= .04), but less Remaining Teeth scores (6 studies; MD = -2.93, 95% CI: -3.91, -1.95; p < .00001). Both the Plaque Index (3 studies; MD = 0.21, 95% CI: 0.14, 0.28; p < .00001) and Gingival Index scores (4 studies; MD = 0.22, 95% CI: 0.14, 0.30; p < .00001) were significantly higher in stroke patients, indicating worse periodontal status.Conclusions: Stroke patients had poorer overall oral health status compared to controls. Given the importance of oral health to overall health, further research on screening for oral health problems after stroke should be conducted and effective management strategies should be devised and implemented.

Perceived barriers and enablers for implementing water protocols in acute stroke care: A qualitative study using the Theoretical Domains Framework

Purpose: To identify perceived enablers and barriers that may influence the implementation of water protocols (WPs) as an intervention for dysphagia in acute stroke settings. Method: Semi-structured interviews were conducted with nine nurses, eight speech-language pathologists (SLPs), five doctors and four dietitians working in acute stroke units in a major city in Australia. Data were thematically analysed and themes were mapped to the Theoretical Domains Framework. Result: Ten barriers and nine enablers were identified. Key barriers were: nurses lack oral care skills and agency nurses lack stroke-specific skills; only SLPs are perceived to be involved with WPs; WP rules will not get followed and may lead to adverse patient outcomes; WPs increase nursing workload; transient workforce impacts efficiency of implementation; and established culture of using thickened fluids. Key enablers were: patients would benefit from WPs; communication and education systems are already in place; acute hospital brings unique benefits; and peer support and modelling support implementation. Conclusion: The perceptions of barriers and enablers to implementation of WPs can be used to inform future studies designed to evaluate the safety and efficacy of WPs and subsequently facilitate their uptake in acute stroke as an alternate dysphagia management strategy.

Oral hygiene practices and knowledge among stroke-care nurses: A multicentre cross-sectional study

AIMS AND OBJECTIVES

To investigate oral health knowledge for stroke care and the clinical practices performed for oral hygiene care in Malaysia.

BACKGROUND

Oral hygiene care following stroke is important as the mouth can act as a reservoir for opportunistic infections that can lead to aspirational pneumonia.

DESIGN

A national cross-sectional survey was conducted in Malaysia among public hospitals where specialist stroke rehabilitation care is provided.

METHODS

All (16) hospitals were invited to participate, and site visits were conducted. A standardised questionnaire was employed to determine nurses' oral health knowledge for stroke care and existing clinical practices for oral hygiene care. Variations in oral health knowledge and clinical practices for oral hygiene care were examined.

RESULTS

Questionnaires were completed by 806 nurses across 13 hospitals. Oral health knowledge scores varied among the nurses; their mean score was 3.7 (SD 1.1) out of a possible 5.0. Approximately two-thirds (63.6%, n = 513) reported that some form of "mouth cleaning" was performed for stroke patients routinely. However, only a third (38.3%, n = 309) reported to perform or assist with the clinical practice of oral hygiene care daily. Their oral health knowledge of stroke care was associated with clinical practices for oral hygiene care (p < .001).

CONCLUSIONS

The clinical practice of providing oral hygiene care is less than ideal, and there are deficiencies in oral health knowledge for stroke care. Oral health knowledge was associated with clinical practice of providing oral hygiene care. This has implications for training and integrating oral hygiene care within stroke rehabilitation.

Risk factors of aspiration pneumonia related to improper oral hygiene behavior in community dysphagia persons with nasogastric tube feeding

Background/purpose

Aspiration pneumonia (AsP) was reported to be closely related to poor oral hygiene. This study aimed to investigate the association between caregivers' oral hygiene behavior with AsP in the community dysphagia persons with nasogastric tube feeding (DPNgTF).

Materials and methods

A cross-sectional study was conducted on 128 DPNgTF and their corresponding caregivers. A self-reported structuralized questionnaire was used to measure the oral care behavior of caregivers. All data analyses were performed using the SPSS. The Chi-square was used for comparison of nonparametric data. Fisher's exact test was used when the expected frequency of any cell in the table was less than five. A p value <0.05 was considered statistically significant.

Results

Fifty-five DPNgTF had developed AsP (43.0%) and they had statistically significantly halitosis (adjusted OR = 4.46; 95%CI = 2.01–9.93), deposition of oropharyngeal secretion (OR = 4.39; 95%CI = 1.99–9.66), dry mouth (OR = 4.23; 95%CI = 1.81–9.85) and closing mouth and not allow to brush (adjusted OR = 2.83; 95%CI = 1.28–6.27). The poor oral hygiene status of DPNgTF was significantly correlated with the occurrence of AsP. The caregivers' oral care to DPNgTF after getting up (OR = 14.09; 95%CI = 2.92–68.08) and using sponge stick to care (OR = 3.29; 95%CI = 1.26–8.55) were the risk factors of AsP.

Conclusion

The implemented oral care after getting up only, using sponge stick has a higher risk compared to the implemented oral care prior to sleeping, using toothbrush. The importance of implementing oral care prior to sleeping by using toothbrush should be reinforced in DPNgTF. Guidelines of oral care and education courses for caregivers during the process in their career training are needed.

Effectiveness of a Web-Based Health Education Program to Promote Oral Hygiene Care Among Stroke Survivors: Randomized Controlled Trial

Background

Oral hygiene care is of key importance among stroke patients to prevent complications that may compromise rehabilitation or potentially give rise to life-threatening infections such as aspiration pneumonia.

Objective

The aim of this study was to evaluate the effectiveness of a Web-based continuing professional development (CPD) program on “general intention” of the health carers to perform daily mouth cleaning for stroke patients using the theory of planned behavior (TPB).

Methods

A double-blind cluster randomized controlled trial was conducted among 547 stroke care providers across 10 hospitals in Malaysia. The centers were block randomized to receive either (1) test intervention (a Web-based CPD program on providing oral hygiene care to stroke patients using TPB) or (2) control intervention (a Web-based CPD program not specific to oral hygiene). Domains of TPB: “attitude,” “subjective norm” (SN), “perceived behavior control” (PBC), “general intention” (GI), and “knowledge” related to providing oral hygiene care were assessed preintervention and at 1 month and 6 months postintervention.

Results

The overall response rate was 68.2% (373/547). At 1 month, between the test and control groups, there was a significant difference in changes in scores of attitude (P=.004) and subjective norm (P=.01), but not in other TPB domains (GI, P=.11; PBC, P=.51; or knowledge, P=.08). At 6 months, there were significant differences in changes in scores of GI (P=.003), attitude (P=.009), SN (P<.001) and knowledge (P=.001) between the test and control groups. Regression analyses identified that the key factors associated with a change in GI at 6 months were changes in SN (beta=.36, P<.001) and changes in PBC (beta=.23, P<.001).

Conclusions

The Web-based CPD program based on TPB increased general intention, attitudes, subjective norms, and knowledge to provide oral hygiene care among stroke carers for their patients. Changing subjective norms and perceived behavioral control are key factors associated with changes in general intention to provide oral hygiene care.

Trial Registration

National Medical Research Register, Malaysia NMRR-13-1540-18833 (IIR); https://www.nmrr.gov.my/ fwbLoginPage.jsp