Oral Hygiene Practices and Status of Stroke Patients Attending an Outpatient Clinic in a Nigerian Tertiary Hospital

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INTRODUCTION
Stroke is defined according to WHO as "rapidly developing clinical signs of focal (or global) disturbance of cerebral function, lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin . 1 It is a leading cause of morbidity and mortality worldwide with increasing incidence and prevalence in developing countries. 2There is a rising burden of stroke in Nigeria and other sub-Saharan African countries with an annual incidence rate of 316 per 100, 000, a prevalence rate of up to 1.4 per 1,000, and a 3-year fatality rate of up to 84%. 3,4compared to what obtains in the developed countries. 5,6Oral functional impairments are prevalent after stroke and include swallowing and eating difficulties, both of which may affect up to 80% of patients. 7,8Facial paresis is an orofacial manifestation of stroke that affects the face and tongue, and may secondarily affect the soft palate 7 Similarly, physical deficits like hand-eye coordination problems, hand or arm deficit may compromise personal oral hygiene efforts. 9oor oral health is by itself a risk factor for cardiovascular disease (CVD), including stroke.A recent analysis of 2013 to 2014 data from the US National Health and Nutrition Examination Survey (NHANES) shows that individuals with fair/poor gum health are more likely to have CVD compared to those who report excellent/very good gum health. 10ven in acute stroke settings, poor oral health is associated with aspiration pneumonia which is one of the predictors of poor outcome.In the multidisciplinary care of stroke patients, the role of the dentist is important in management and rehabilitation.Such a role involves advising and assisting in acute care service and maintaining proper oral health care during the early stage, following stroke. 7In subsequent periods of rehabilitation, the services may include the provision of preventive and restorative care. 11However, despite the obvious need for dental care, dentists are hardly involved in the routine management of patients with stroke in both inpatient and outpatient settings.The association between periodontal diseases and stroke was proposed by Millard and Marcken, 12 and the suggested mechanism involves the initiation of an inflammatory process caused by microbacteria in the subgingival and supragingival plaque in the crevicular fluid.The proposed mechanism involves the inflammatory process leading to the aggregation of platelets, formation of thrombosis, and subsequent embolism.This, in turn, is suggested as a fundamental mechanism in the formation of stroke.In summary, the study suggests that periodontal diseases may contribute to stroke by triggering inflammation and thrombosis through the presence of microbacteria in oral plaque.It is important to note that while there is some evidence suggesting a link between oral health and cardiovascular diseases, including stroke, further research is needed to establish a clear cause-andeffect relationship and to understand the underlying mechanisms in more detail.Maintaining good oral hygiene and regular dental check-ups are generally recommended for overall health and well-being.Despite the high and escalating burden of stroke in Nigeria and other sub-Saharan African countries which may adversely affect oral health, there is paucity of information on oral hygiene and oral health status of stroke survivors.This study aimed to assess the oral hygiene and oral health status of patients with stroke who were attending the neurology outpatient clinic of a tertiary hospital in Nigeria.

MATERIALS AND METHODS
This descriptive, cross-sectional study was conducted from 2016 to 2020 at the Neurology Clinic of the University of Ilorin Teaching Hospital in North Central Nigeria.The clinic is run by 3 neurologists, supported by postgraduate resident doctors.The hospital has a stroke unit that provides in-patient care for about 150 stroke patients per year and about 8-10 patients attend the clinic for follow-up per week.After obtaining informed consent to participate, all eligible patients were consecutively recruited.Eligibility criteria included being an adult (at least 18 years of age), with a neuroimaging confirmation with either computed tomography or magnetic resonance imaging and at the time of recruitment in the clinic, the participant must be at least 30 days post-stroke.The study was approved by the Institutional Review Board of the hospital with approval number ERCPAN/2015/03/1517.A pre-tested semi-structured questionnaire was used to obtain the necessary information from the attending neurologists and trained research assistants who were resident doctors rotating through the neurology unit.Information obtained were the sociodemographic characteristics, strokerelated symptoms, duration of a stroke, history of www.njdres.compresence or absence of hypertension, presence or absence of aphasia, facial nerve palsy, and muscle power in the limbs (graded from 0-5) using the medical research council grading system, 13 and functional status using the modified Rankin Scale (mRS).The mRS is a disability assessment scale used as an outcome measure in stroke patients.Six distinct disability ratings are defined by the mRS: grade 0 denotes "no symptoms at all," grade 5 denotes "severe disability or bedridden, incontinent, and requiring constant nursing care and attention," and grade 6 denotes death.A modified Rankin scale (mRS) score ≤2 was graded as good functional status while 3-5 was graded as poor. 14ral hygiene practices were assessed by asking questions on frequency of daily tooth brushing, and prior utilization of dental services.A highly experienced dentist conducted a detailed oral examination on each patient and assessed the oral hygiene status using the Simplified Oral Hygiene Index which is composed of a combination of the Debris Index (DI) and the Calculus Index (CI).Each of these indices is based on numerical determinations representing the amount of debris or calculus found on the buccal and lingual surfaces of the preselected teeth.The maxillary and mandibular arches were examined in four quadrants, each being examined for debris and/or calculus.Six surfaces were selected from the four posterior and two anterior teeth for examination for OHI-S.In the posterior portion of the dentition, usually the first molar but sometimes the second or third molar was examined.The buccal surfaces of the selected upper molars and the lingual surfaces of the selected lower molars were inspected.In the anterior portion of the mouth, the labial surfaces of the upper right and the lower left central incisors were scored.For each individual, the debris scores were summed and divided by the number of surfaces scored.At least two of the six possible surfaces had to be scored and examined before the final scores were calculated.The same methods were used to obtain the calculus score.The DI and the CI were combined to obtain the OHI-S.The CI and DI values range from 0 to 3; the OHI-S values from 0 to 6, with lower scores indicating better oral hygiene.The OHI-S is the gold standard for the assessment of oral hygiene. 6Simplified Oral Hygiene Index was rated according to the guidelines published by Greene and Vermillion 15 ; a score of 0-1.2 was rated as good, 1.3-3.0 as fair and 3.1-6.0as poor.The caries status was determined using the DMFT index, 16 that is the number of decayed, missing, and filled teeth individually with the use of a standard dental mirror and probe, and was expressed as the DMFT means while modified gingival index (MGI) 17 was used to identify the presence or absence of gingival diseases.Dental examination was carried out by using sterile dental instruments (mouth mirrors and explorers) under natural light.Data analysis Data was analyzed using the Statistical Product and Service Solutions (SPSS) version 20.0 (SPSS Inc, Chicago, Il.) . 18Relevant sociodemographic and clinical characteristics were presented as frequency (percentages), while continuous variables were presented as means and standard deviation.The conditional logistic regression method was used to determine the factors associated with oral hygiene status which was dichotomized into two categories ("good/fair" and "poor").Variables that were entered into the logistic regression model included age, sex, muscle power, aphasia, facial nerve palsy and modified Rankin score.The independent predictors of poor oral hygiene status were determined using the backward elimination logistic regression method.Results of the multivariate logistic regression analysis were presented as odd ratios with 95% confidence intervals and level of significance (p) set at <0.05.RESULTS A total of 120 patients (male 62.5%) with a mean age of 60.30±13.21(range 21-91) years participated in the study.Only 49 (40.8%) of the patients had at least 12 years of formal education (minimum of senior secondary level of education)( ≥ primary).Eighty per cent had hypertension as the dominant modifiable risk factor for stroke.Modified Rankin Scale (mRS) score was good (≤ 2) in 73.3% of the study participants.These are shown in Table 1.

Oral Hygiene Practices among Participants
In this study, 33.3% of the respondents had utilized dental services previously.The common reason for dental service utilization was dental extraction due to toothache (8.3%), while other reasons were scaling and polishing (1%) and dental checkup (1%).Seventy (70%) of the patients brushed their teeth once a day.There was no significant association between the frequency of tooth brushing and their modified Rankin score (p=0.937).

Oral Hygiene index and its predictors
As shown in Figure 1, only 28.8% had good oral hygiene status while 29.7% had poor oral hygiene.Conditional logistic regression analysis showed that a modified Rankin score of 3-5 predicted poor oral hygiene status (OR 1.367; 95% CI 1.020-1.832;p=0.036).(Table 2

DISCUSSION
This study analyzed and evaluated the oral hygiene index and its predictors in stroke survivors.The results show that about one-third of the participants, had poor oral hygiene status and a modified Rankin score of 3-5 was an independent risk factor for this observation.This is not entirely surprising since 32 (26.7%) of our stroke patients had a high degree of disability and required assistance with self-care and activities of daily living, putting them at risk of having poor oral hygiene..It has been demonstrated that factors like advanced age, lower Barthel index score (a measure of the degree of dependence) and higher modified Rankin score among others are associated with poor oral hygiene status in stroke patients 9 .Despite a high proportion of our study participants having good functional status as assessed by the modified Rankin score, this measure of functional status emerged as the independent predictor of oral hygiene status.Patients with a mRS score of 3-5 (poor functional outcome) are about 37% at higher risk of poor oral hygiene status compared to those with lower mRS scores.This is not surprising because these are patients with moderate to severe disability which would impair adequate self-care.It is thus imperative that those with poor modified Rankin scores should have assistance with oral care during their rehabilitation as their frequency and intensity of tooth brushing may be comparatively lower compared to that of apparently healthy individuals and stroke patients with good functional status.The fact that about 70% of our patients brushed once daily shows that probable ineffective brushing This study reported a dental service utilization rate of 33.3%, which is than the 23.9% reported by Osadolor et al 24 but lower than the 50% reported by Kim et al. 25 Symptomatic reasons emerged as the predominant motivation for seeking dental services, a trend consistent with earlier studies 26,27,28 .Ajayi et al, 29 further underscored fear-related conditions as a primary obstacle to oral healthcare uptake within the studied demography.Among these, apprehension towards dental injections ranked highest.The phenomenon of dental anxiety and pain-related fears in dentistry was noted to have persisted notwithstanding advancements in dental technology, procedures, and preventative measures.29 is imperative to acknowledge that disparities in utilization rates across studies may be attributed to other multiple contributory factors.Notably, the constrained availability of dental services in the present study locale, coupled with potential impediments posed by high treatment costs and a shortage of adequately trained dental professionals, may serve as plausible explanations for the observed lower utilization rate.This observation corroborates the findings of Ajayi et al. 29 These considerations are of paramount significance in formulating strategies aimed at enhancing oral health care accessibility and utilization within the study community.Moreso, participants in this study may have prioritized other healthcare needs over dental care due to a lack of awareness about the importance of oral health.On the other hand, the higher utilization rate reported by Kim et al. 25 could be attributed to differences in the study population or methodology.The mean DMF among stroke patients ranged from 8.57±7.10to21.6±9.7 as reported in previous studies. 30,31It is however lower in the present study.This could be because most of our participants received care in the tertiary institution and also have tertiary education.Almost half of the participants (40%) experienced dental caries, the probable explanation for this could be due to oral sensorimotor impairment leading to the accumulation of plaque and food debris on the tooth causing dental caries.Our study indicates that 23.3% of participants exhibited signs of gingival diseases (periodontal diseases), a prevalence notably lower than reported rates in analogous investigations.For example, Yunus 27 reported a substantially higher prevalence of 99.4% in their study population, highlighting substantial variability.This variance in prevalence rates can be ascribed to diverse factors, including sample size, demographic heterogeneity, and cultural distinctions among nations.CONCLUSION Poor oral hygiene status was common among the participants, with those who have poor functional status being at higher risk.It is thus imperative that oral health is considered in the holistic rehabilitation of every stroke patient.Those with poor functional status will need assistance with oral care because of the limitation of their ability to brush properly which will negatively affect their oral health.To reduce the accumulation of food particles in the oral cavity, a comprehensive oral hygiene instruction that may include instruction on the use of an electric toothbrush, large hand-held toothbrush, and water irrigation instrument coupled with plaque-revealing tablets and running a washcloth chlorhexidine through the vestibule may be needed in stroke patients, especially those with poor functional status.LIMITATION Our study was limited to only stroke patients who were on follow-up at the outpatient clinic, hence our findings need to be interpreted within this context.However, if inpatients were included, the overall oral health status reported could have been worse than what we found because of the higher degree of disability at that stage.RECOMMENDATION The assessment of patients in the acute phase of a stroke and documenting their oral health status is highly recommended.This will improve outcomes through the early institution of prevention and avoidable complication like aspiration pneumonia to which a patient with poor oral health status could be highly susceptible.Source of support Nil Conflict of Interest None declared

Figure 1 :
Figure 1: Oral Hygiene Status of study participants www.njdres.combecause of disability could have contributed negatively to their oral health status.

Table 1 :
) Sociodemographic and clinical characteristics of study participants

Table 2 :
Predictors of Poor Oral Hygiene Status on Conditional Logistic Regression