A study on oral rehabilitation in stroke patients: analysis of a group of 33 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.

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.

Does Diabetes Induce the Vascular Endothelial Growth Factor (VEGF) Expression in Periodontal Tissues? A Systematic Review

Aim: Diabetes and periodontal disease are both chronic pathological conditions linked by several underlying biological mechanisms, in which the inflammatory response plays a critical role, and their association has been largely recognized. Recently, attention has been given to diabetes as an important mediator of vascular endothelial growth factor (VEGF) overexpression in periodontal tissues, by virtue of its ability to affect microvasculature. This review aims to summarize the findings from studies that explored VEGF expression in diabetic patients with periodontitis, compared to periodontally healthy subjects. Materials and Methods: A systematic literature review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A PubMed search of select medical subject heading (MeSH) terms was carried out to identify all studies reporting findings about VEGF expression in periodontal tissues of diabetic patients up to May 2018. The inclusion criteria were studies on VEGF expression in periodontally diseased tissues of diabetic patients compared with nondiabetic subjects, with any method of analysis, and published in the English language. Results: Eight articles met the inclusion criteria. Immunohistochemistry was used in six of the studies, reverse transcriptase polymerase chain reaction (real-time RT-PCR) aiming to quantify mRNA VEGF expression was used in one study, and ELISA analysis was used for one study. Compared with nondiabetic patients, a higher VEGF expression in gingival tissue and gingival crevicular fluid (GCF) samples in diabetic patients with periodontitis was reported. Conclusions: Overall, novel evidence for the VEGF expression within the periodontal tissue of diabetic patients paves the way for further studies on the role of this protein in neovascularization physiology and pathophysiology in microvasculature of the periodontium.

Orofacial Functions and Chewing Effiency in Elderly Patients with Parkinson’s Disease Rehabilitated with Removable Prostheses

Background:

Parkinson’s Disease (PD) is the second most common neurodegenerative disease after Alzheimer's disease. It is one of the movement disorders that can affect oro-facial conditions. It is more common in the elderly, having an average age of onset of around 60 years.

Objective:

The aim was to study orofacial functions in patients suffering from PD with partial or total edentulism, wearing removable prostheses.

Methods:

Forty-eight (48) elders, rehabilitated with removable dentures, were included: 24 patients suffering from Parkinson's disease constitute the Study Group (SG), and 24 subjects not suffering from Parkinson's disease or neurological degenerative diseases represent the Control Group (CG).

In SG, the severity of Parkinson's disease was assessed according to the Unified Parkinson's Disease Rating objective motor scale III, and oro-facial dysfunctions were evaluated using Nordic Orofacial Test-Screening (NOT-S). The duration of the use of dental prostheses expressed in years has been reported. In both the groups, the subjective chewing index for the analysis of masticatory ability and the two-color chewing gum test for the analysis of masticatory efficiency were conducted .

Results:

There was a statistically significant difference between the SG and CG compared to the NOT-S (P = 0.001).

Analyzing the study group, a statistically significant correlation was found between the masticatory efficiency and prosthetic years of use (rs = 0.436; P <0.05); instead, no statistically significant correlation was found between the masticatory efficiency and the severity of Parkinson's disease.

Conclusion:

In our study, we did not find differences between SG and CG in terms of the degree of masticatory efficiency; therefore, only a correlation between the duration of use of dental prostheses and the degree of masticatory efficiency was found.

Removable Prosthetic Treatment in Oral Pemphigus Vulgaris: Report of Three Cases

Pemphigus vulgaris (PV) is the most common clinical phenotype affecting the oral mucosa. Although rare, this vesicular disease may represent a severe complication in the management of edentulous or partially dentate patients because of the priority of care in handling the oral tissues. Analysis of the dental literature indicated a lack of evidence about the possibility of rehabilitating PV patients with removable prosthesis. Our study aimed to evaluate and describe the possibility of rehabilitating three patients who suffered from oral PV with removable prosthesis, although the friction of the prosthesis on oral soft tissues is one of the causes of the development of vesicular lesions which could break, causing oral mucosal pain and erosion. Three patients, referred to the Oral Pathology and Medicine section of the Dental School in Bari University, underwent biopsy, direct and indirect immunofluorescence tests, and enzyme-linked immunosorbent assay to confirm the diagnosis of oral PV. For each patient, a systemic corticosteroid therapy was planned. After the clinical remission of the PV signs, the patients were planned for an oral rehabilitation with removable prosthesis. As long as certain precautions are followed, patients with PV in a phase of clinical remission, induced by treatment, can be treated successfully with removable prosthesis. Although some authors have previously cautioned about the use of removable prosthesis for the treatment of patients with oral pemphigus, it is our view that, if patients follow the rigorous and periodic follow-up as discussed above, along with a corticosteroid immunosuppressive therapy, they may not show any deterioration of their clinical symptoms.

Obstructive site localization in patients with Obstructive Sleep Apnea Syndrome: a comparison between otolaryngologic data and cephalometric values

Purpose

Obstructive Sleep Apnea Syndrome (OSAS) is a respiratory disorder characterized by repeated obstructive episodes affecting upper airways.This study aims at examining the anatomical craniofacial and pharyngeal characteristics of the patient as to identify the obstructive site which triggers the pathologic process.Correlations between otolaryngologic data observed in the patient and the cephalometric ones for the identification of the obstructive site were also highlighted.

Materials and methods

We worked on a sample of 16 patients, 12 males and 4 females, attended to at the Otolaryngology Operative Unit of Bari University Hospital.The patients underwent an otolaryngologic (ORL) diagnostic procedure which provided for ApneaGraph (AG) recording, and a dental diagnostic procedure with cephalometric assessment.

Results

The statistical analysis highlighted a strict correlation between the otolaryngologic value of AHI and the cephalometric values of the ANB angle, with the distance between the hyoid bone and the mandibular plane and with the distance between the hyoid bone and the plane passing between C3 and Me.

Conclusions

We observed a concurrence between the ORL diagnosis of the obstruction level assessed with AG and the cephalometric values regarding respiratory tracts (IPAS and SAS). More precisely, we observed the correlation between the otolaryngologic value of AHI with cephalometric values of the ANB angle, with the distance between hyoid bone and mandibular plan, and with the distance between the hyoid bone and the plane passing between C3 and Me. Furthermore, the identification of the caudal position of the hyoid bone can be considered an alarm bell in the diagnosis of severe OSAS.

Early mandibular canine-lateral incisor transposition: case report

Purpose

The main aim of the present study is to present a case of mandibular transposition between lateral incisor and canine in a paediatric patient.

Materials and methods

A fixed multibracket orthodontic treatment was performed by means of a modified welded arch as to correct the transposition and obtaining a class I functional and symmetrical occlusion, also thanks to the early diagnosis of the eruption anomaly.

Results

Our case report shows that a satisfactory treatment of mandibular transpositions is obtained when detected at an early stage of the tooth development.

Conclusions

The main treatment options to be taken into consideration in case of a mandibular transposition are two: correcting the transposition or aligning it leaving the dental elements in their transposed order; in both cases, the follow-ups show a stable condition, maintained without relapses. Several factors, such as age of the patient, occlusion, aesthetics, patient's collaboration, periodontal support and duration of treatment have to be considered as to prevent potential damage to dental elements and support appliances. The choice between the two treatment approaches for mandibular lateral incisor/canine transpositions mainly depends on the time the anomaly is detected.

Multiparameter Electromyography Analysis of the Masticatory Muscle Activities in Patients with Brainstem Stroke at Different Head Positions

The performance of the masticatory muscle is frequently affected and presents high heterogeneity poststroke. Surface electromyography (EMG) is widely used to quantify muscle movement patterns. However, only a few studies applied EMG analysis on the research of masticatory muscle activities poststroke, and most of which used single parameter—root mean squares (RMS). The aim of this study was to fully investigate the performance of masticatory muscle at different head positions in healthy subjects and brainstem stroke patients with multiparameter EMG analysis. In this study, 15 healthy subjects and six brainstem stroke patients were recruited to conduct maximum voluntary clenching at five different head positions: upright position, left rotation, right rotation, dorsal flexion, and ventral flexion. The EMG signals of bilateral temporalis anterior and masseter muscles were recorded, and parameters including RMS, median frequency, and fuzzy approximate entropy of the EMG signals were calculated. Two-way analysis of variance (ANOVA) with repeated measures and Bonferroni post hoc test were used to evaluate the effects of muscle and head position on EMG parameters in the healthy group, and the non-parametric Wilcoxon signed rank test was conducted in the patient group. The Welch–Satterthwaite t-test was used to compare the between-subject difference. We found a significant effect of subject and muscles but no significant effect of head positions, and the masticatory muscles of patients after brainstem stroke performed significantly different from healthy subjects. Multiparameter EMG analysis might be an informative tool to investigate the neural activity related movement patterns of the deficient masticatory muscles poststroke.

Maxillary Overdenture Retained with an Implant Support CAD-CAM Bar: A 4 Years Follow Up Case

Introduction:

Oral rehabilitation with overdenture on implants of upper jaw must be taken into consideration a variety of anatomical and biomechanical issues. It is possible to provide for rehabilitation with two or more implants, in different positions, solidarizing them with a bar.

Materials & Methods:

The present study involved a patient rehabilitated with 4 Xive implants (Friadent GmbH, Mannheim, Germany) solidarized with a titanium bar crafted with CAD-CAM technology for maximal comfort, precision and structural lightness.

Results & Discussion:

The follow-up was 54 months, with an implant survival of 100%. Based on our clinical evidence, bars engineered with CAD-CAM technology are promising in terms of precision and comfort despite higher costs.

Correlation between parodontal indexes and orthodontic retainers: prospective study in a group of 16 patients

PURPOSE

Fixed retainers are used to stabilize dental elements after orthodontic treatment. Being it a permanent treatment, it is necessary to instruct patients about a constant and continuous monitoring of their periodontal conditions and a correct oral hygiene. The aim of this study was to highlight the possible adverse effects of bonded retainers on parameters correlated to the health conditions of periodontal tissues.

MATERIALS AND METHODS

We selected 16 patients, under treatment in the Orthodontics Department of University of Bari Dental School, who had undergone a lingual retainer insertion at the end of the orthodontic treatment. The patients were then divided into two groups (Control Group and Study Group) and monitored for 3 and 36 months, respectively. The following indexes were taken into consideration: gingival index (GI), plaque index (PI) and the presence of calculus (Calculus Index, CI), the probing depth and the presence of gingival recession on the six inferior frontal dental elements.

RESULTS

After the observation was carried out, any of the patients showed periodontal sockets and gingival recession. In the Study Group, only 1 patient had a PI score=3, the 7 left had scores between 0.66 and 2.83. In the Control Group, one patient had score=0, the other ones showed values between 0.5 and 1.66. The mean GI in the Study Group peaked at a score of 2.83, the minimum was 0.66; whereas in the Control Group the maximum value was 2 and the minimum 0.66. The CI in the Group Study was between 1 and 2. In the Control Group it was absent in only 1 patient, whereas in the remaining 7, it had a value between 0.3 and 1. The clinical data were studied by means of the Wilcoxon test. We found a statistically significant difference for what concerns the Plaque Indexes (PI) (P>0.05) and Calculus Indexes (CI) (P>0.1) in both groups, with higher scores in the Study Group, having retainers for 36 months. Any statistically significant difference was calculated for the GI.

CONCLUSIONS

We can therefore conclude that patients with lingual retainers need periodontal hygiene and treatment as to prevent, in the course of time, periodontal damages non-detectable in short-term.

Oral health status in patients with acquired brain injury: a systematic review

OBJECTIVE

To undertake a systematic review of the current knowledge and future perspectives regarding the status of various oral health factors, including social and behavioral aspects, in patients with acquired brain injury (ABI).

STUDY DESIGN

A structured search strategy was applied to PubMed, Embase, and Scopus electronic databases until January 2016 to identify studies presenting assessments of the oral health status of patients afflicted with any kind of ABI. The search strategy was restricted to English-language publications that enrolled patients aged more than 18 years. Studies on the association of oral health conditions and brain injury were excluded. No study was excluded based on its qualitative analysis.

RESULTS

A total of 27 studies were reviewed. Stroke was the most commonly studied ABI. Stroke patients had a higher number of missing teeth, poorer plaque and gingival index scores, and higher colonization of Candida albicans in saliva, all of which were significantly reduced after intervention. Oral health-related quality of life was poorer in patients compared to the general population.

CONCLUSION

Stroke was the most predominant brain injury condition studied in the literature, with few publications focusing on other forms of brain injury. Overall, oral health has been noted to be poor in patients with ABI, but oral hygiene and oral health-related quality of life have been found to improve when oral hygiene interventions are provided to patients.

Relationship between removable prosthesis and some systemics disorders

This article reviews the dental literature concerning the potential impact of the removable prosthesis (RP) on the health status of patients with certain systemic diseases. Literature was surveyed using Medline/PubMed database resources, as well as a manual search, up to 2015 to identify appropriate articles that addressed the aim of this review. The research used keywords about associations between RP and six pathologies: Human immunodeficiency virus infection, diabetes mellitus, pulmonary diseases, gastric-Helicobacter pylori, cancer, and cardiovascular diseases. Analysis of literature showed that in patients with dentures having one or more of the six general conditions listed, Candida albicans organism is more frequently found in the oral flora compared to healthy denture wearer. Although causality has not been established and pending further research on this topic, the hygienic practices necessary to minimize the risk of numerous pathologies should be strengthened in the case of these patients, all the more in the presence of physical or psychological disability. The relationship between the general diseases and increasing of oral candidiasis denture patients is not explained. Therefore, attention to oral hygiene and professional care for removing C. albicans may be beneficial in these medically compromised patients.

Oral hygiene in patients with oral cancer undergoing chemotherapy and/or radiotherapy after prosthesis rehabilitation: protocol proposal

PURPOSE

This study was aimed at assessing the effectiveness and the importance of an oral hygiene (OH) protocol in patients undergoing radiation therapy and chemotherapy after prosthesis rehabilitation, in order to reduce or minimize oral complications.

MATERIALS AND METHODS

This study was carried out at the Department of Dental Science, at the University of Bari-Italy from December 2012 to December 2015 on 34 selected patients with primary oral cancer undergoing chemotherapy and radiotherapy after prosthesis rehabilitation. They were divided into 2 groups according to their age, sex and cancer therapy. Seventeen patients were assigned to the control group and seventeen in the experimental one. In the experimental group (Table 1), patients underwent an oral hygiene protocol whereas in the control group (Table 2) patients received the usual care provided within the clinical setting. All the patients gave written informed consent. It has been asked and obtained the authorisation from the Ethics Committee of the Dental Science and Surgery Department.

RESULTS

Results show that in patients undergoing the oral hygiene protocol, the complications and the risks of infection and permanent dental problems have been minimized. Indeed, of the seventeen patients undergoing the OH protocol, 70% obtained positive results and were satisfied with the program outcome.

CONCLUSIONS

The role of the health care providers is essential to educate patients to adhere to the prescribed treatments and reinforce their motivation in oral hygiene. The oral hygiene procedures prevent and ameliorate oral complications due to the radiation therapy and chemotherapy.

Influence of oral health condition on swallowing and oral intake level for patients affected by chronic stroke

BACKGROUND

According to the literature, the occurrence of dysphagia is high in cases of stroke, and its severity can be enhanced by loss of teeth and the use of poorly fitting prostheses.

OBJECTIVE

To verify that the status of oral health influences the level of oral intake and the degree of swallowing dysfunction in elderly patients with stroke in chronic phase.

METHODS

Thirty elderly individuals affected by stroke in chronic phase participated. All subjects underwent assessment of their oral condition, with classification from the Functional Oral Intake Scale (FOIS) and nasoendoscopic swallowing assessment to classify the degree of dysphagia. The statistical analysis examined a heterogeneous group (HG, n=30) and two groups designated by the affected body part, right (RHG, n=8) and left (LHG, n=11), excluding totally dentate or edentulous individuals without rehabilitation with more than one episode of stroke.

RESULTS

There was a negative correlation between the need for replacement prostheses and the FOIS scale for the HG (P=0.02) and RHG (P=0.01). Differences in FOIS between types of prostheses of the upper dental arch in the LHG (P=0.01) and lower dental arch in the RHG (P=0.04). A negative correlation was found between the number of teeth present and the degree of dysfunction in swallowing liquid in the LHG (P=0.05). There were differences in the performance in swallowing solids between individuals without prosthesis and those with partial prosthesis in the inferior dental arch (P=0.04) for the HG.

CONCLUSION

The need for replacement prostheses, type of prostheses, and the number of teeth of elderly patients poststroke in chronic phase showed an association with the level of oral intake and the degree of oropharyngeal dysphagia.

A systematic review and meta-analysis of clinical, microbiological, and behavioural aspects of oral health among patients with stroke

OBJECTIVE

The objective of this study was to review clinical, microbiological, and immunological aspects of oral health, as well as oral health related behaviours among patients following stroke.

DATA SOURCES

A structured search strategy was applied to three electronic databases to identify relevant papers.

STUDY SELECTION

The initial search yielded 19,927 papers, 60 potentially relevant studies (Kappa: 0.974) and 23 relevant papers (Kappa: 0.965) in accordance with the inclusion criteria. Outcomes regarding tooth condition, periodontal condition, oral hygiene status, and dental attendance were pooled for seven meta-analyses. Narrative summaries were provided for those outcomes which could not be pooled for meta-analysis.

RESULTS

The standardized differences in mean values of the parameters (fixed effect, random effect model) for patients with stroke compared to control groups were: number of teeth (-0.325, -0.271), DMFT (0.246, 0.246), oral hygiene status - plaque index (0.305, 0.356) and gingival index (0.716, 0.653), periodontal health status - clinical attachment loss (0.437, 0.490) and probing depth (0.470, 0.579). In addition, a lower chance of dental attendance was observed among patients with stroke (odds ratio: 0.493, 0.480). For those outcomes which could not be pooled for meta-analysis, it was not possible to draw any qualitative conclusion due to the equivocal results of these studies.

CONCLUSIONS

There is an increasing interest in oral health of patients with stroke. Patients with stroke had a poorer clinical oral health status across a range of parameters (tooth loss, dental caries experience, and periodontal status). Coupled with this, their dental attendance was less frequent. Further studies employing standardized assessments of oral health/oral health behaviour can confirm these oral health disparities.

CLINICAL SIGNIFICANCE

With comprehensive literature search, this systematic review and meta-analysis indicated a poorer oral health status and less frequent dental attendance behaviour among patients with stroke.