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Meta-Analysis
. 2020 Dec 7;12(12):CD003864.
doi: 10.1002/14651858.CD003864.pub3.

Interventions for improving oral health in people after stroke

Pauline Campbell  1 , Brenda Bain  1 , Denise Lc Furlanetto  2 , Marian C Brady  1
Affiliations
Meta-Analysis

Interventions for improving oral health in people after stroke

Pauline Campbell et al. Cochrane Database Syst Rev. .

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 methods: 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.

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.

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Conflict of interest statement

PC: none.

BB: has been involved in one trial included in this review (see SOCLE II), but was not involved in the assessment or interpretation of this trial.

DF: none.

MB: has been involved in one trial included in this review (see SOCLE II), but was not involved in the assessment or interpretation of this trial.

Figures

1
1
Study flow diagram. RCT: randomised controlled trial.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1: Oral health care (OHC) interventions versus usual care, Outcome 1: Dental plaque (up to 1 month)
1.2
1.2. Analysis
Comparison 1: Oral health care (OHC) interventions versus usual care, Outcome 2: Dental plaque (6 months)
1.3
1.3. Analysis
Comparison 1: Oral health care (OHC) interventions versus usual care, Outcome 3: Denture plaque
1.4
1.4. Analysis
Comparison 1: Oral health care (OHC) interventions versus usual care, Outcome 4: Presence of oral disease: gingivitis (up to 1 month)
1.5
1.5. Analysis
Comparison 1: Oral health care (OHC) interventions versus usual care, Outcome 5: Presence of oral disease: gingivitis (6 months)
1.6
1.6. Analysis
Comparison 1: Oral health care (OHC) interventions versus usual care, Outcome 6: Denture‐induced stomatitis
1.7
1.7. Analysis
Comparison 1: Oral health care (OHC) interventions versus usual care, Outcome 7: Pneumonia
1.8
1.8. Analysis
Comparison 1: Oral health care (OHC) interventions versus usual care, Outcome 8: OHC knowledge (1 month)
1.9
1.9. Analysis
Comparison 1: Oral health care (OHC) interventions versus usual care, Outcome 9: OHC knowledge (2 months)
1.10
1.10. Analysis
Comparison 1: Oral health care (OHC) interventions versus usual care, Outcome 10: OHC knowledge (6 months)
1.11
1.11. Analysis
Comparison 1: Oral health care (OHC) interventions versus usual care, Outcome 11: Attitudes to oral care (1 month)
1.12
1.12. Analysis
Comparison 1: Oral health care (OHC) interventions versus usual care, Outcome 12: Attitudes to oral care (2 months)
1.13
1.13. Analysis
Comparison 1: Oral health care (OHC) interventions versus usual care, Outcome 13: Attitudes to oral care (6 months)
2.1
2.1. Analysis
Comparison 2: Oral health care (OHC) interventions versus placebo, Outcome 1: Presence of oral disease: pneumonia
2.2
2.2. Analysis
Comparison 2: Oral health care (OHC) interventions versus placebo, Outcome 2: Presence of oral disease: acquired Aerobic Gram‐negative bacilli (AGNB)
2.3
2.3. Analysis
Comparison 2: Oral health care (OHC) interventions versus placebo, Outcome 3: Presence of oral disease: carriage of AGNB
2.4
2.4. Analysis
Comparison 2: Oral health care (OHC) interventions versus placebo, Outcome 4: Self‐reported oral dryness
3.1
3.1. Analysis
Comparison 3: Oral health care (OHC) interventions versus another OHC intervention, Outcome 1: Dental plaque (3 months)
3.2
3.2. Analysis
Comparison 3: Oral health care (OHC) interventions versus another OHC intervention, Outcome 2: Dental plaque (6 months)
3.3
3.3. Analysis
Comparison 3: Oral health care (OHC) interventions versus another OHC intervention, Outcome 3: Presence of oral disease: aerobic Gram‐negative bacilli (AGNB) (3 months)
3.4
3.4. Analysis
Comparison 3: Oral health care (OHC) interventions versus another OHC intervention, Outcome 4: Presence of oral disease: AGNB (6 months)
3.5
3.5. Analysis
Comparison 3: Oral health care (OHC) interventions versus another OHC intervention, Outcome 5: Candida (3 months)
3.6
3.6. Analysis
Comparison 3: Oral health care (OHC) interventions versus another OHC intervention, Outcome 6: Candida (6 months)
3.7
3.7. Analysis
Comparison 3: Oral health care (OHC) interventions versus another OHC intervention, Outcome 7: Staphylococcus aureus
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Ab Malik 2017 {published data only}
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Kobayashi 2017iii {published data only}
    1. Kobayashi K, Ryu M, Izumi S, Ueda T, Sakurai K. Effect of oral cleaning using mouthwash and a mouth moisturizing gel on bacterial number and moisture level of the tongue surface of older adults requiring nursing care. Geriatrics Gerontology International 2017;17(1):116-21. - PubMed
Kobayashi 2017iv {published data only}
    1. Kobayashi K, Ryu M, Izumi S, Ueda T, Sakurai K. Effect of oral cleaning using mouthwash and a mouth moisturizing gel on bacterial number and moisture level of the tongue surface of older adults requiring nursing care. Geriatrics Gerontology International 2017;17(1):116-21. - PubMed
Kobayashi 2017v {published data only}
    1. Kobayashi K, Ryu M, Izumi S, Ueda T, Sakurai K. Effect of oral cleaning using mouthwash and a mouth moisturizing gel on bacterial number and moisture level of the tongue surface of older adults requiring nursing care. Geriatrics Gerontology International 2017;17(1):116-21. - PubMed
Kobayashi 2017vi {published data only}
    1. Kobayashi K, Ryu M, Izumi S, Ueda T, Sakurai K. Effect of oral cleaning using mouthwash and a mouth moisturizing gel on bacterial number and moisture level of the tongue surface of older adults requiring nursing care. Geriatrics Gerontology International 2017;17(1):116-21. - PubMed
Kuo 2016 {published data only}
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Lam 2013i {published data only}
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Lam 2013ii {published data only}
    1. Lam OL, McGrath C, Samaranyake L, Li LS. Evaluation of oral hygiene interventions in patients following acute stroke. 89th General Session of the International Association for Dental Research; 2011 Mar 16-19; San Diego (CA).
    1. Lam OL, McMillan AS, Samaranayake LP, Li LS, McGrath C. Effect of oral hygiene interventions on opportunistic pathogens in patients after stroke. American Journal of Infection Control 2013;41:149-54. - PubMed
    1. Lam OL, McMillan AS, Samaranayake LP, Li LS, McGrath C. Randomized clinical trial of oral health promotion interventions among patients following stroke. Archives of Physical Medicine and Rehabilitation 2013;94:435-43. - PubMed
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Lam 2013iii {published data only}
    1. Lam OL, McGrath C, Samaranyake L, Li LS. Evaluation of oral hygiene interventions in patients following acute stroke. 89th General Session of the International Association for Dental Research; 2011 Mar 16-19; San Diego (CA).
    1. Lam OL, McMillan AS, Samaranayake LP, Li LS, McGrath C. Effect of oral hygiene interventions on opportunistic pathogens in patients after stroke. American Journal of Infection Control 2013;41:149-54. - PubMed
    1. Lam OL, McMillan AS, Samaranayake LP, Li LS, McGrath C. Randomized clinical trial of oral health promotion interventions among patients following stroke. Archives of Physical Medicine and Rehabilitation 2013;94:435-43. - PubMed
    1. NCT01265043. A clinical trial on the effect of chlorhexidine mouth rinse and assisted tooth brushing on the health condition and quality of life of elderly stroke patients. clinicaltrials.gov/ct2/show/NCT01265043 (first received 22 December 2010).
Lee 2011 {published data only}
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Seguin 2014 {published data only}
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SOCLE II {published data only}
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References to studies excluded from this review

Boden‐Albala 2016 {published data only}
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Brailsford 2002 {published and unpublished data}
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Duck‐Won 2013 {published data only}
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Hägglund 2017 {published data only}
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Jones 2007 {published data only (unpublished sought but not used)}
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Lee 2017 {published data only}
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Mojon 1998 {published data only}
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Murray 2016 {unpublished data only}
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NCT01777672 {unpublished data only}
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NCT02379182 {unpublished data only}
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NCT02541032 {unpublished data only}
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Quagliarello 2009 {published data only}
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References to studies awaiting assessment

Cabov 2010 {published data only}
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IRCT2017012232101N1 {published data only}
    1. IRCT2017012232101N1. Comparing the effect of Ortodentol and chlorhexidine mouthwashes 10% and /12 percent on oral hygiene intubated patients in intensive care units. en.irct.ir/trial/25092 (first received 2 April 2017).
IRCT2017091636194N1 {published data only}
    1. IRCT2017091636194N1. The comparison of the impact of Nanosil and Chlorhexidine mouthwashes in an oral decontamination plan on the occurrence of ventilator associated pneumonia in hospitalised patients in the intensive care unit. en.irct.ir/trial/27125 (first received 7 October 2017).
Jin 2018 {published data only}
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Marchini 2018 {published data only}
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    1. Marchini L, Recker E, Hartshorn J, Cowen H, Lynch D, Drake D, et al. Iowa nursing facility oral hygiene (INFOH) intervention: a clinical and microbiological pilot randomized trial. Special Care in Dentistry 2018;38(6):345-55. - PMC - PubMed
    1. NCT02668809. Oral hygiene intervention pilot study. clinicaltrials.gov/ct2/show/NCT02668809 (first received 29 January 2016).
Mori 2012 {published data only}
    1. Mori C, Hakuta C, Endo K, Nariaia T, Ueno M, Shinada K, et al. The effects of professional oral health care on patients in the subacute stage of emergent neurosurgical disorders. Special Care in Dentistry 2012;32(6):259-64. - PubMed
NCT00610324 {published data only}
    1. NCT00610324. Effect of oral decontamination using chlorhexidine or potassium permanganate in ICU patients. clinicaltrials.gov/ct2/show/record/NCT00610324 (first received 7 February 2008).
NCT03219346 {unpublished data only}
    1. NCT03219346. The effectiveness of oral health in improving dysphagia of patients after stroke of swallowing function and oral health quality of life. clinicaltrials.gov/show/NCT03219346 (first received 17 July 2017).
Yakiwchuk 2013 {published data only}
    1. Yakiwchuk C-A, Bertone M, Ghlabi E, Brown S, Llarakos M, Brothwell DJ. Suction toothbrush use for dependent adults with dysphagia: a pilot examiner blind randomized clinical trial. Canadian Journal of Dental Hygiene 2013;47(1):15-23.

References to ongoing studies

ChiCTR‐IPR‐17013403 {published and unpublished data}
    1. ChiCTR-IPR-17013403. Effect of oral care on the incidence of pneumonia in acute stroke patients with different degrees of dysphagia. www.chictr.org.cn/showproj.aspx?proj=22474 (first received 15 November 2017).
Hollaar 2015 {published data only}
    1. Hollaar V, Maarel-Wierink C, Putten GJ, Swart B, Baat C. Effect of daily application of a 0.05% chlorhexidine solution on the incidence of (aspiration) pneumonia in care home residents: design of a multicentre cluster randomised controlled clinical trial. BMJ 2015;5(12):e007889. - PMC - PubMed
    1. NL3367. The effect of chlorhexidine on the incidence of aspiration pneumonia in care home residents: design of a double-blind cluster randomized placebo-controlled trial. www.trialregister.nl/trial/3367 (first received 9 July 2012).
MAPS‐2 {published data only}
    1. ISRCTN14124645. Metoclopramide and selective oral decontamination for avoiding pneumonia after stroke. www.isrctn.com/ISRCTN14124645 (first received 10 October 2016).
    1. Roffe C, Warusevitane A, Smith C, Gosney M, Knox E, Buttery A, et al. The Metoclopramide and selective oral decontamination for Avoiding Pneumonia after Stroke (MAPS-2) trial: a 2x2 double-blind, randomized controlled trial of metoclopramide and selective oral decontamination for the prevention of pneumonia in patients with dysphagia after an acute stroke. 12th UK Stroke Forum Conference; 2017 Nov 28-30; Liverpool (UK).
    1. Roffe C. The Metoclopramide and selective oral decontamination for Avoiding Pneumonia after Stroke trial: a 2x2 double-blind, randomized controlled trial of metoclopramide and selective oral decontamination for the prevention of pneumonia in patients with dysphagia after an acute stroke. www.keele.ac.uk/maps2/ (accessed prior to 30 September 2020).

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References to other published versions of this review

Brady 2006
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Publication types