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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 13  |  Issue : 5  |  Page : 233-236  

Evaluation of oral hygiene status in patients with hemorrhagic and ischemic stroke


1 Community Health Centre, Amnour, Saran, Bihar, India
2 Department of Dentistry, Darbhanga Medical College And Hospital, Darbhanga, Bihar, India
3 Primary Health Centre, Baniyapur, Saran, Bihar, India
4 Department of Orthodontics and Dentofacial Orthopedics, Buddha Institute of Dental Sciences and Hospital, Patna, Bihar, India
5 Dental Medical Officer, Primary Health Centre, Health Department, Government of Bihar, Rajpur, Rohtas, Bihar, India
6 Department of Oral and Maxillofacial Surgery, Buddha Institute of Dental Sciences and Hospital, Patna, India

Date of Submission22-Oct-2020
Date of Decision26-Oct-2020
Date of Acceptance27-Oct-2020
Date of Web Publication05-Jun-2021

Correspondence Address:
Raman Kant Sinha
Community Health Centre, Amnour, Saran, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpbs.JPBS_698_20

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   Abstract 


Background: Stroke can broadly be categorized into ischemic or hemorrhagic. Ischemic stroke accounts for 85% of cerebrovascular accidents (CVAs), whereas hemorrhagic stroke accounts for 15% of CVAs. Stroke is broadly associated with loss of sensation or unilateral paralysis of orofacial structures. Objectives: The present study was conducted to evaluate the prevalence of various oral features in patients with ischemic and hemorrhagic stroke. Materials and Methods: One hundred patients diagnosed with stroke admitted in the intensive care unit were included in the study. The evaluation of oral manifestations and their prevalence was done by a well-experienced oral medicine expert deputed in the dental department of the hospital. A single examiner performed all oral evaluations. Results: The mean and median for the age were 60.8 and 59. Sixty of 100 patients were male, whereas 38 were female. Forty patients had hemorrhagic stroke, whereas 60 had ischemic stroke. Senenty-eight patients of 100 had features of periodontitis, 90 of 100 patients presented with halitosis, 79 presented with caries, 83 patients had positive signs of tongue hypermobility, and 75 patients had dysphagia. Conclusion: Oral hygiene is the most neglected aspect during rehabilitation in stroke patients. It is critical for stroke patients to receive thorough oral care, as it can prevent other systemic ailments and potentially life-threatening complications like aspiration pneumonia.

Keywords: Halitosis, hemorrhage, ischemia, periodontitis, stroke, tongue hypermobility


How to cite this article:
Sinha RK, Singh A, Kishor A, Richa S, Kumar R, Kumar A. Evaluation of oral hygiene status in patients with hemorrhagic and ischemic stroke. J Pharm Bioall Sci 2021;13, Suppl S1:233-6

How to cite this URL:
Sinha RK, Singh A, Kishor A, Richa S, Kumar R, Kumar A. Evaluation of oral hygiene status in patients with hemorrhagic and ischemic stroke. J Pharm Bioall Sci [serial online] 2021 [cited 2021 Jun 19];13, Suppl S1:233-6. Available from: https://www.jpbsonline.org/text.asp?2021/13/5/233/317632




   Introduction Top


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

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

Clinical presentation

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

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

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


   Materials and Methods Top


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


   Results Top


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

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Table 2: Data analysis of oral symptoms in hemorrhagic stroke

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Table 3: Data analysis of oral symptoms in ischemic stroke

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   Discussion Top


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

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

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

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

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

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

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


   Conclusion Top


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

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Khaku AS, Tadi P. Cerebrovascular Disease (Stroke). In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2020.  Back to cited text no. 1
    
2.
Fatahzadeh M, Glick M. Stroke: Epidemiology, classification, risk factors, complications, diagnosis, prevention, and medical and dental management. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:180-91.  Back to cited text no. 2
    
3.
Dai R, Lam OL, Lo EC, Li LS, McGrath C. Oral health-related quality of life in patients with stroke: A randomized clinical trial of oral hygiene care during outpatient rehabilitation. Sci Rep 2017;7:7632.  Back to cited text no. 3
    
4.
Memetoglu OG, Taraktas A, Badur NB, Ozkan FU. Impact of stroke etiology on clinical symptoms and functional status. North Clin Istanb 2014;1:101-5.  Back to cited text no. 4
    
5.
Musuka TD, Wilton SB, Traboulsi M, Hill MD. Diagnosis and management of acute ischemic stroke: Speed is critical. CMAJ 2015;187:887-93.  Back to cited text no. 5
    
6.
Chugh C. Acute ischemic stroke: Management approach. Indian J Crit Care Med 2019;23:S140-6.  Back to cited text no. 6
    
7.
Patel AR, Patel AR, Desai S. The underlying stroke etiology: A comparison of two classifications in a rural setup. Cureus 2019;11:e5157.  Back to cited text no. 7
    
8.
Hanley DF, Awad IA, Vespa PM, Martin NA, Zuccarello M. Hemorrhagic stroke: Introduction. Stroke 2013;44:S65-6.  Back to cited text no. 8
    
9.
Hui C, Tadi P, Patti L. Ischemic Stroke. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020.  Back to cited text no. 9
    
10.
Cereda C, Carrera E. Posterior cerebral artery territory infarctions. Front Neurol Neurosci 2012;30:128-31.  Back to cited text no. 10
    
11.
Wardlaw JM. What causes lacunar stroke? J Neurol Neurosurg Psychiatry 2005;76:617-9.  Back to cited text no. 11
    
12.
Pillai RS, Iyer K, Spin-Neto R, Kothari SF, Nielsen JF, Kothari M. Oral health and brain injury: Causal or casual relation? Cerebrovasc Dis Extra 2018;8:1-5.  Back to cited text no. 12
    
13.
Habibi-Koolaee M, Shahmoradi L, Niakan Kalhori SR, Ghannadan H, Younesi E. Prevalence of stroke risk factors and their distribution based on stroke subtypes in gorgan: A retrospective hospital-based study-2015-2016. Neurol Res Int 2018;2018:2709654.  Back to cited text no. 13
    
14.
Fekadu G, Chelkeba L, Kebede A. Risk factors, clinical presentations and predictors of stroke among adult patients admitted to stroke unit of Jimma university medical center, south west Ethiopia: prospective observational study. BMC Neurol 2019;19:187.  Back to cited text no. 14
    
15.
Mary Grace N, Shameer V.K., Rajesh K.R, Raghavan R, Sreejesh, Sakti. A prospective observational study on the clinical profile of ischemic stroke in a tertiary care centre in Thrissur, Kerala. Int J Med Res Rev 2016;4:1371-5.  Back to cited text no. 15
    
16.
Hashemipour MA, Afshar AJ, Borna R, Seddighi B, Motamedi A. Gingivitis and periodontitis as a risk factor for stroke: A case-control study in the Iranian population. Dent Res J (Isfahan) 2013;10:613-619.  Back to cited text no. 16
    
17.
Rose LF, Mealey B, Minsk L, Cohen DW. Oral care for patients with cardiovascular disease and stroke. J Am Dent Assoc 2002;133:37S-44S.  Back to cited text no. 17
    
18.
Pradeep AR, Hadge P, Arjun Raju P, Shetty SR, Shareef K, Guruprasad CN. Periodontitis as a risk factor for cerebrovascular accident: A case-control study in the Indian population. J Periodontal Res 2010;45:223–8.  Back to cited text no. 18
    
19.
Kim J, Amar S. Periodontal disease and systemic conditions: A bidirectional relationship. Odontology 2006;94:10-21.  Back to cited text no. 19
    
20.
Kim HT, Park JB, Lee WC, Kim YC Lee Y. Differences in the oral health status and oral hygiene practices according to the extent of post-stroke sequelae. J Oral Rehabil 2018;45:476-84.  Back to cited text no. 20
    
21.
Fagundes NC, Almeida AP, Vilhena KF, Magno MB, Maia LC, Lima RR. Periodontitis as a risk factor for stroke: A systematic review and meta-analysis. Vasc Health Risk Manag 2019;15:519-32.  Back to cited text no. 21
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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