Interventions for improving oral health in people after stroke

Review question

We wanted to know whether oral healthcare (OHC) interventions improve the oral health of people who have had a stroke, and if any one OHC intervention provided more benefit than another approach.

Background

Three quarters of people who have had a stroke experience physical problems, and the weakness, lack of co-ordination and cognitive (attention, memory, language and orientation) problems that may accompany a stroke can make it difficult for a person to maintain the health and cleanliness of their mouth, tongue and teeth on their own. A clean mouth feels good and the practice of OHC (removing dental plaque (a soft, sticky film that builds up on your teeth) and traces of food) is a crucial factor in maintaining the health of the mouth, teeth and gums. A clean and healthy mouth also prevents pain or discomfort and allows people to eat a range of nutritious foods. Maintaining good oral care may be difficult after a stroke and healthcare staff may have to assist in providing such care.

We wanted to see whether OHC interventions could improve the cleanliness of stroke survivors' teeth by reducing dental plaque or denture plaque (our primary outcomes). We were also interested in whether OHC interventions would improve other (secondary) outcomes including patient satisfaction and quality of life, presence of oral disease, presence of related infection, and stroke survivor and providers' knowledge and attitudes to OHC.

Search date

The evidence is current to February 2019.

Study characteristics

We included 15 studies (22 comparisons) involving 1546 people with stroke, 1028 staff and 94 carers in this updated review. Seven trials compared OHC with usual care; three trials compared OHC with placebo (pretend treatment or usual care), and 12 trials compared two different types of OHC.

Key results

We found little evidence to inform how OHC is best delivered. There was low-quality evidence from trials that compared OHC with standard care showing that OHC reduced denture plaque. There was no difference for studies that measured dental plaque. We found very low-quality evidence to show that training nursing staff and family carers improved their knowledge and attitudes to OHC. There was low-quality evidence that demonstrated the beneficial impact of a decontamination gel (to reduce the number of bacteria in the mouth) on the incidence of pneumonia compared with placebo gel among patients in a stroke ward. However, there was no other information on how best to provide OHC and more studies are urgently needed.

Quality of the evidence

Despite the inclusion of several new trials of OHC for people after stroke since our last review update there remains a lack of high-quality evidence to inform OHC in stroke care settings.

Conclusion

We judged the quality of the current evidence in this review to be low to very low. We lack high-quality evidence of the optimal approach to providing OHC to people after stroke. Additional well-conducted clinical trials are needed.

Authors' conclusions: 

We found low- to very low-quality evidence suggesting that OHC interventions can improve the cleanliness of patient's dentures and stroke survivor and providers' knowledge and attitudes. There is limited low-quality evidence that selective decontamination gel may be more beneficial than placebo at reducing the incidence of pneumonia. Improvements in the cleanliness of a patient's own teeth was limited. We judged the quality of the evidence included within meta-analyses to be low or very low quality, and this limits our confidence in the results. We still lack high-quality evidence of the optimal approach to providing OHC to people after stroke.

Read the full abstract...
Background: 

For people with physical, sensory and cognitive limitations due to stroke, the routine practice of oral health care (OHC) may become a challenge. Evidence-based supported oral care intervention is essential for this patient group.

Objectives: 

To compare the effectiveness of OHC interventions with usual care or other treatment options for ensuring oral health in people after a stroke.

Search strategy: 

We searched the Cochrane Stroke Group and Cochrane Oral Health Group trials registers, CENTRAL, MEDLINE, Embase, and six other databases in February 2019. We scanned reference lists from relevant papers and contacted authors and researchers in the field. We handsearched the reference lists of relevant articles and contacted other researchers. There were no language restrictions.

Selection criteria: 

We included randomised controlled trials (RCTs) that evaluated one or more interventions designed to improve the cleanliness and health of the mouth, tongue and teeth in people with a stroke who received assisted OHC led by healthcare staff. We included trials with a mixed population provided we could extract the stroke-specific data. The primary outcomes were dental plaque or denture plaque. Secondary outcomes included presence of oral disease, presence of related infection and oral opportunistic pathogens related to OHC and pneumonia, stroke survivor and providers' knowledge and attitudes to OHC, and patient satisfaction and quality of life.

Data collection and analysis: 

Two review authors independently screened abstracts and full-text articles according to prespecified selection criteria, extracted data and assessed the methodological quality using the Cochrane 'Risk of bias' tool. We sought clarification from investigators when required. Where suitable statistical data were available, we combined the selected outcome data in pooled meta-analyses. We used GRADE to assess the quality of evidence for each outcome.

Main results: 

Fifteen RCTs (22 randomised comparisons) involving 3631 participants with data for 1546 people with stroke met the selection criteria.

OHC interventions compared with usual care

Seven trials (2865 participants, with data for 903 participants with stroke, 1028 healthcare providers, 94 informal carers) investigated OHC interventions compared with usual care.

Multi-component OHC interventions showed no evidence of a difference in the mean score (DMS) of dental plaque one month after the intervention was delivered (DMS –0.66, 95% CI –1.40 to 0.09; 2 trials, 83 participants; I2 = 83%; P = 0.08; very low-quality evidence).

Stroke survivors had less plaque on their dentures when staff had access to the multi-component OHC intervention (DMS –1.31, 95% CI –1.96 to –0.66; 1 trial, 38 participants; P < 0.0001; low-quality evidence).

There was no evidence of a difference in gingivitis (DMS –0.60, 95% CI –1.66 to 0.45; 2 trials, 83 participants; I2 = 93%; P = 0.26: very low-quality evidence) or denture-induced stomatitis (DMS –0.33, 95% CI –0.92 to 0.26; 1 trial, 38 participants; P = 0.69; low-quality evidence) among participants receiving the multi-component OHC protocol compared with usual care one month after the intervention. There was no difference in the incidence of pneumonia in participants receiving a multi-component OHC intervention (99 participants; 5 incidents of pneumonia) compared with those receiving usual care (105 participants; 1 incident of pneumonia) (OR 4.17, CI 95% 0.82 to 21.11; 1 trial, 204 participants; P = 0.08; low-quality evidence).

OHC training for stroke survivors and healthcare providers significantly improved their OHC knowledge at one month after training (SMD 0.70, 95% CI 0.06 to 1.35; 3 trials, 728 participants; I2 = 94%; P = 0.03; very low-quality evidence). Pooled data one month after training also showed evidence of a difference between stroke survivor and providers' oral health attitudes (SMD 0.28, 95% CI 0.01 to 0.54; 3 trials, 728 participants; I2 = 65%; P = 0.06; very low-quality evidence).

OHC interventions compared with placebo

Three trials (394 participants, with data for 271 participants with stroke) compared an OHC intervention with placebo. There were no data for primary outcomes. There was no evidence of a difference in the incidence of pneumonia in participants receiving an OHC intervention compared with placebo (OR 0.39, CI 95% 0.14 to 1.09; 2 trials, 242 participants; I2 = 42%; P = 0.07; low-quality evidence). However, decontamination gel reduced the incidence of pneumonia among the intervention group compared with placebo gel group (OR 0.20, 95% CI 0.05 to 0.84; 1 trial, 203 participants; P = 0.028). There was no difference in the incidence of pneumonia in participants treated with povidone-iodine compared with a placebo (OR 0.81, 95% CI 0.18 to 3.51; 1 trial, 39 participants; P = 0.77).

One OHC intervention compared with another OHC intervention

Twelve trials (372 participants with stroke) compared one OHC intervention with another OHC intervention. There was no difference in dental plaque scores between those participants that received an enhanced multi-component OHC intervention compared with conventional OHC interventions at three months (MD –0.04, 95% CI –0.33 to 0.25; 1 trial, 61 participants; P = 0.78; low-quality evidence). There were no data for denture plaque.

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