Salivary Secretion and Occlusal Force in Patients with Unilateral Cerebral Stroke

Oral Health Status and Salivary Parameters in Stroke Patients at a Tertiary Hospital

Introduction: Dental caries and impaired salivary function are very common but undertreated. The aim of this study was to investigate the oral health status and salivary parameters of stroke patients. Methods: A cross-sectional study was carried out on 54 stroke and 54 non-stroke patients attending rehabilitation treatment at Hospital Universiti Sains Malaysia. Decay, Missing and Filled Teeth (DMFT) index and plaque scores were used to evaluate patients’ oral health. Salivary parameters such as salivary cortisol, salivary flow rate, pH and buffering capacity were measured. Salivary cortisol was analysed using Cobas E6000 automated immunoassay. Results: Among the 54 stroke patients, the majority were Malays 72.2% and 63.0% were male, with a mean age of 48.1 (14) years. There was a significant difference of dental caries between stroke patients, at 17.6 (4.26), compared to 15.7 (5.38) for non-stroke patients (p=0.042). Only 53.7% of stroke patients had good oral hygiene, compared to, 85.2% among non-stroke patients’ (p-value= 0.001). Salivary parameters showed no significant differences (p>0.05). However salivary cortisol levels were higher in stroke patients 5.2(5.1) nmol/L) than in non-stroke patients 4.0 (3.6) nmol/L). There was no significant correlation between salivary parameters and DMFT index (P>0.05). Conclusion: Stroke patients had more dental caries and poor oral hygiene compared to non-stroke patients. Salivary parameters showed no significant difference between stroke and non-stroke patients.

Clinical Characteristics and Rehabilitation Strategies for the Stomatognathic System Disturbances in Patients with Stroke: A Systematic Review

Background: Understanding the stomatognathic system disturbances is key to diagnosing them early and implementing rehabilitation approaches to promote functional recovery. The objective of this study was to systematically review all published data that examined the assessment and rehabilitation strategies for the stomatognathic system disturbances in patients with stroke. Methods: Five databases (i.e., PubMed/MEDLINE, Scopus, Science Direct, Web of Science, and PEDro), were screened for manuscripts that included the assessment and rehabilitation strategies for stomatognathic system disturbances. The methodological quality was evaluated using the Mixed Methods Appraisal Tool. Results: Sixteen articles were included in this systematic review. The most frequently reported symptoms in patients with stroke included stiffness and thickness of the masseter muscle on the affected side and suprahyoid muscles; facial muscles' asymmetry and weakness; temporomandibular disorders; and a reduced maximum lip force, tongue pressure, and saliva flow rate. The rehabilitation strategies more frequently reported included exercises directed to the jaw, temporomandibular joint, tongue, and neck. The mean score for methodological quality was 85%. Conclusion: The stomatognathic system disturbances are frequently reported among patients with stroke, leading to dysfunction in masticatory performance or swallowing. More studies on interventions for stomatognathic system disturbances are required before conclusions may be drawn. Key Practitioner Message: This systematic review has clinical implications for rehabilitation practices, given that the results may help to develop early assessment and rehabilitation strategies for stomatognathic disturbances in patients with stroke.

Associations of general health conditions with masticatory performance and maximum bite force in older adults: A systematic review of cross-sectional studies

OBJECTIVES

To give an overview of the current evidence on the associations of general health conditions with masticatory performance and maximum bite force in older adults.

DATA/SOURCES

Three electronic databases (Medline via PubMed, Embase via Ovid and CINAHL Plus via EBSCOhost) were searched up to September 2021 for cross-sectional studies on general health conditions and masticatory performance or maximum bite force in older adults. Methodological quality of the included studies was independently evaluated based on Joanna Briggs Institute critical appraisal checklist for analytical cross-sectional studies. Data on the associations between general health conditions and masticatory performance or maximum bite force were extracted.

STUDY SELECTION

Of the 5133 records identified, 39 studies (43 articles) were included in this review. Significant negative associations were found between masticatory performance and stroke, sarcopenia, amyotrophic lateral sclerosis, chronic obstructive pulmonary disease, dyspepsia, dysphagia, anorexia, and carotid atherosclerosis. Significant negative association was found between maximum bite force and sarcopenia. There were equivocal results on the association between masticatory performance and diabetes mellitus, and between maximum bite force and stroke, and amyotrophic lateral sclerosis. There was no significant association between masticatory performance and metabolic syndrome, and between maximum bite force and progress of Parkinson's disease. Most studies revealed positive associations of physical function with masticatory performance and maximum bite force.

CONCLUSIONS

Negative associations between masticatory function of older adults and presence of several systemic diseases have been reported in a number of studies while there are positive associations between masticatory function and some physical function indicators.

CLINICAL SIGNIFICANCE

This study provides valuable information on the association of masticatory function with general health, which draws clinicians' attention to the masticatory function of older adults who suffer from certain systemic diseases or physical dysfunction, and to the need to improve their masticatory ability to achieve healthy aging.

Association between oral health status and oral food intake level in subacute stroke patients admitted to a convalescent rehabilitation unit

BACKGROUND

Stroke patients often suffer from dysphagia during their recovery. We hypothesised that subacute stroke patients with dysphagia had more deteriorated oral health status including muscle strength and motor function.

OBJECTIVE

Quantitatively investigate oral health status and identify associations with oral feeding status in stroke patients admitted to a convalescent rehabilitation unit.

METHODS

We prospectively recruited 187 stroke patients admitted to a convalescent rehabilitation unit. Oral feeding status was examined using the Functional Oral Intake Scale (FOIS), and the cohort was divided into three groups based on FOIS score as non-oral feeding (FOIS-123; 22 patients), dysphagic diet (FOIS-45; 74 patients), and regular diet (FOIS-67; 91 patients) groups. Activities of daily living (ADL) were assessed with the Functional Independence Measure (FIM). Oral health status was measured quantitatively in six oral function parameters and Oral Health Assessment Tool (OHAT), and differences according to the FOIS, age and FIM were statistically tested.

RESULTS

In bivariate analysis, two parameters, tongue pressure and tongue-lip motor functions were significantly higher in the regular diet group than in the other groups (P < .01). Gross OHAT score was also significantly better in the regular diet group than in the other groups (P < .01). These significant associations mostly remained in the multiple model after adjusting for age and FIM.

CONCLUSION

This study suggests that, amongst oral health status, tongue strength and motor function, as well as OHAT score, may have strong associations with oral feeding status in subacute stroke patients at convalescent rehabilitation units regardless of ADL levels.

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.

Temporomandibular Joint Dysfunction and Impaired Stomatognathic Alignment: A Problem Beyond Swallowing in Patients With Stroke

The aim of this study is to evaluate the efficacy of supervised structured exercise programme in post stroke patients with temporomandibular joint dysfunction (TMJD). 30 post stroke patients diagnosed as TMJD according to "diagnostic criteria for temporomandibular disorders" (DC/TMD) were included for the study. A structured exercise programme including active and active-assisted range of motion (ROM) exercises for neck and temporomandibular joint (TMJ), chins tuck exercises, breathing and relaxing exercises and posture exercises were performed. Cervical ROMs including flexion, extansion, lateral flexion and rotation, Mann assessment of swallowing ability (MASA) and mini mental state exam (MMSE) scores, maximal mouth opening (MMO) and craniomandibular index (CMI) of the patients compared at baseline, 1st and 6th month after supervised rehabilitation procedure. All parameters were significantly improved both in 1st and 6th month evaluation. At 6th month evaluation, the cervical ROMs of the patients improved from severe to mild restriction (p = 0.001), the mean MASA score of the patients improved from moderate to mild swallowing disorder (p = 0.001), mean MMSE score of 30 patients was accepted as normal (p = 0.001), mean MMO of the patients was 56.00 ± 4.84 mm and mean CMI was 0.16 ± 0.05 indicating that the patients had a "mild" limitation in mouth opening and "mild" dysfunction in TMJ (p = 0.001 respectively). Our structured supervised exercise programme improves swallowing quality by establishing proper stomatognathic alignment and TMJ function.

Effect of implant-supported mandibular overdentures versus reline on masticatory performance and salivary flow rates in very old adults-A randomized clinical trial

PURPOSE

To compare the masticatory efficiency (ME), maximum voluntary bite force (MBF), masseter muscle thickness (MMT), and salivary flow rates (SFR) in completely edentulous dependent elders treated either with a conversion of their existing mandibular complete removable dental prostheses (CRDPs) into a two-implant overdenture (IOD) or a conventional reline of the CRDP.

MATERIAL AND METHODS

Participants were randomly allocated into intervention (IG) and control (CG) groups. The IG received two implants in the mandibular canine regions, and their CRDPs were transformed into IODs. The CG received a conventional reline of their mandibular CRDPs. Outcomes were recorded at each recall visit (baseline, immediately, 3 months, 12 months after intervention, and subsequently on an annual basis). Statistical analyses used mixed linear regression models (level of significance: p < 0.05).

RESULTS

The IG comprised 16 participants (age = 85.0 ± 6.2 years), while the CG comprised 16 (age = 84.8 ± 5.4 years), with a mean follow-up of 2.7 ± 2.2 years (range: 3 months-7 years). A significant increase of MBF in the IG was observed with an overall gain of 80 N (p < 0.001) compared with the reline group. There were no significant long-term changes in SFR, MMT, or ME within/between groups.

CONCLUSION

Since dependent elders with mandibular IODs present a significant gain in MBF, but no relative increase in SFR, MMT, and ME, it seems that this increased capacity of MBF is not exploited by the elders during their habitual chewing.

Assessment of Temporomandibular Joint Dysfunction in Patients with Stroke

GOAL

The aim of this study was to assess temporomandibular joint dysfunction in patients with stroke.

MATERIALS AND METHODS

Total of 100 participants, 50 healthy and 50 who had stroke, were recruited into this study. Digital caliper and algometer were used to assess temporomandibular joint range of motion and masticatory muscle pressure pain threshold. Labial commissure angle measurement was used for the assessment of facial paralysis severity. Fonseca questionnaire was used for temporomandibular joint dysfunction assessment and categorization. In addition, dominant mastication shift was measured by the question that asks the pre and poststroke dominant mastication side.

FINDINGS

In intergroup comparison, significant decrease was found in all temporomandibular range of motion parameters in favor of stroke group (P < .05). Despite the fact that no significant difference was found between groups for the pain threshold in masticatory muscles except for middle part of the left temporalis muscle, values were higher in healthy group (P > .05). As a result of intergroup examination of labial commissure angle degree, Fonseca questionnaire score, it was found that labial commissure angle and Fonseca questionnaire scores were higher in stroke group (P < .05). Intragroup examination of patients with stroke showed that dominant mastication side shift was seen in patients with stroke (P < .05).

CONCLUSION

It was concluded that, temporomandibular joint dysfunction prevalence was higher in stroke group compared with healthy group and use of modalities specific to temporomandibular joint dysfunction treatment would be beneficial.

Oro-facial impairment in stroke patients

Stroke is considered one of the leading causes of death and acquired disability with a peak prevalence over the age of 80 years. Stroke may cause debilitating neurological deficiencies that frequently result in sensory deficits, motor impairment, muscular atrophy, cognitive deficits and psychosocial impairment. Oro-facial impairment may occur due to the frequent involvement of the cranial nerves' cortical representation areas, central nervous system pathways or motoneuron pools. The aim of this narrative, non-systematic review was to discuss the implications of stroke on oro-facial functions and oral health-related quality of life (OHRQoL). Stroke patients demonstrate an impaired masticatory performance, possibly due to reduced tongue forces and disturbed oral sensitivity. Furthermore, facial asymmetry is common, but mostly discrete and lip restraining forces are reduced. Bite force is not different between the ipsi- and contra-lesional side. In contrast, the contra-lesional handgrip strength and tongue-palate contact during swallowing are significantly impaired. OHRQoL is significantly reduced mainly because of the functional impairment. It can be concluded that impaired chewing efficiency, dysphagia, facial asymmetry, reduced lip force and OHRQoL are quantifiable symptoms of oro-facial impairment following a stroke. In the absence of functional rehabilitation, these symptoms seem not to improve. Furthermore, stroke affects the upper limb and the masseter muscle differently, both, at a functional and a morphological level. The rehabilitation of stroke survivors should, therefore, also seek to improve the strength and co-ordination of the oro-facial musculature. This would in turn help improve OHRQoL and the masticatory function, subsequently preventing weight loss and malnutrition.

Parotid gland atrophy in patients with chronic trigeminal nerve denervation

BACKGROUND AND PURPOSE

Trigeminal nerve injury or dysfunction is associated with denervation atrophy of muscles innervated by the mandibular branch of the trigeminal nerve. The purpose of our study was to evaluate the association between chronic CN V denervation and parotid gland atrophy.

MATERIALS AND METHODS

Twenty-six patients with chronic masticator muscle atrophy were retrospectively identified and evaluated for the presence of ipsilateral parotid gland atrophy. Twenty-six age-matched control subjects with no clinical or imaging evidence of chronic masticator space atrophy were also identified. Segmentation of the parotid gland was performed to calculate a parotid asymmetry index. The Fisher exact test and t test were respectively used to determine the correlation between parotid gland atrophy and ipsilateral masticator muscle atrophy and to evaluate any difference in the size of the involved parotid gland when compared with that in the control subjects.

RESULTS

Ipsilateral parotid gland atrophy was seen in 9/26 (42.8%) patients with fatty replacement of the masticator group of muscles, suggesting a correlation between parotid gland atrophy and CN V denervation (P<.001). The parotid asymmetry index was significantly different in patients with CN V denervation (0.59±0.25) compared with control subjects (0.92±0.03) (P<.001).

CONCLUSIONS

Ipsilateral parotid gland atrophy can accompany chronic CN V denervation change, and its clinical significance remains to be determined.