Post-stroke Dental Care
There are a number of post-stroke dental-care challenges for survivors, including sensation deficits, changes in taste and saliva flow, tongue protrusion and ability to successfully expectorate (spit) and swish effectively. In addition, dental care is a conglomeration of fine-motor skills, so stroke can have an impact on a survivors’ teeth and gums, and that in turn can increase stroke risk. Bacteria and biofilm, which are always in our mouths, combined with poor oral hygiene cause gum disease.
The onset of gum disease often begins as gingivitis (gum disease), which is easily reversible with proper dental care. But, if left untreated, the bacteria and biofilm associated with gingivitis continue to grow and thrive below your gums. Left unchecked, the biofilm will continue to grow and cause further damage, leading to inflammation and a loss of bone around your teeth. This becomes a more serious condition known as periodontitis (gum and bone disease).
The biofilm, sometimes referred to as plaque, continues to thrive, eating and eliminating waste inside the gum tissue. In turn, that buildup causes bacteria to form, which can enter the bloodstream through your mouth.
Controlling plaque, and the biofilm that causes it, is a daily activity. Most of us learned early in childhood the importance of brushing our teeth. A stroke doesn’t make daily oral care any less important, but it may make it harder for survivors to hold and manipulate a toothbrush and floss. “As far as toothbrushing is concerned, you can accommodate a stroke survivor with adaptive devices so they can grip the toothbrush,” said nurse and dental hygienist Mary Signorino of St. Louis. These devices go over the handle of the toothbrush, making it larger and easier to grasp for those with a weakened grip. A Google search of “adaptive toothbrush handles” will produce many options, but it may be easy and more affordable to adapt a toothbrush with common items around your home, such as:
- a handle bar grip from a bike
- a tennis ball with holes to put the toothbrush handle through
- grips from tools
Collis Curve toothbrush
Another option that increases the effectiveness of brushing is a special toothbrush called a Collis Curve®. It’s a three-sided toothbrush that has bristles on both sides as well as the middle. “It brushes the top of the tooth and the sides at the same time,” Signorino said.
Example of toothbrush handle modified with a wash cloth for gripping
Example of toothbrush handle modified with a tennis ball for gripping
Instead of adapting a regular toothbrush, survivors may also opt for an electric toothbrush. There are several varieties to choose from, some with vibrating heads, others with heads that spin. “The Sonicare© toothbrush is a well-balanced brush with good research behind it. It’s good quality and has a good warranty,” Signorino said. “Oral-B© electric toothbrushes spin and do a good job. There are cheaper spin brushes, too. The vibration is different with each brand, and it all depends on how that vibration feels to the individual.”
Brushing disrupts the biofilm on the top and sides of the teeth, but biofilm also grows between the teeth and below the gum line. This is the stuff that semi-annual dental cleanings address, but the plaque starts to grow within hours of the cleaning. Flossing is the only way to keep that infestation at bay.
Signorino is a big believer in flossing. “If you want to decrease your dental bill, decrease your risk of tooth decay, your risk of gum disease, and increase the benefit of general good health, flossing is key,” she said.
But even for people with two well-functioning hands, flossing can be a challenge, and for survivors with fine-motor skill deficits, it can be daunting. Luckily there are aids. “One floss aid that has been around for decades is a dental floss holder,” she said. “It looks like a little tuning fork. You thread the floss between the two arms and push the floss between your teeth. Its handle is long enough to reach behind your back teeth.”
There are also floss picks that come with the floss already taut between two arms and facilitate flossing — they look like a little coping saw. In additional to flossing, there are interdental or interproximal brushes, small cone-shaped brushes that slide between your teeth at the gumline and sweep out the biofilm. Signorino insists they are not a substitute for flossing, but an additional device. A completely different alternative is water flossers (brand name WaterPik®). Water flossers use a jet of water to disrupt plaque formation. “You want to keep it on a setting of 5,” she said.
Floss now comes in colors and flavors. “The nice thing about using a colored floss is that when you take that floss out of your mouth, you’re able to see the white biofilm on it,” Signorino said. But colored floss is no more effective than white floss.
In addition to dental floss, there is dental tape. “I think dental tape is better for stroke survivors than dental floss,” Signorino said. “That’s because the tape is flat, so when you put it against the tooth, it flattens out, and you get a little more surface area, which allows you to remove more biofilm.”
While you are in your mouth, don’t forget about your tongue. “Your tongue is covered in papillae, they’re like blades of grass,” Signorino said. “The tongue is bathed in saliva, and there is biofilm in the saliva. More biofilm is accumulated because your tongue licks your teeth. So, taking care of your tongue is very important. There are a variety of tongue scrapers out there. There are also tongue brushes. Some people have a separate toothbrush that they use on their tongue. Some people use their regular toothbrush to brush their tongue. I prefer a tongue scraper or a separate brush.”
Challenges after stroke
Stroke can affect oral health in other ways than making preventive care difficult. “Probably the most common condition I encounter is dry mouth,” she said. “That’s an ongoing problem for a lot of people, not just stroke survivors, and it increases the likelihood of cavities. To battle it, a person needs to take sips of water frequently, or they can suck on sugarless candies. And don’t drink alcohol or caffeinated beverages. And don’t smoke. There are salivary substitutes like XyliMelts®, Oralbalance© and Biotène©. For survivors with dysphagia, I recommend swabbing their mouth with oral care sponges saturated with water. But there’s really nothing that can make it 100 percent of how it was when your salivary glands were at their best.”
According to the Centers for Disease Control and Prevention, gingivitis can be controlled and treated with good oral hygiene and regular professional cleaning. More severe forms of periodontal disease can also be treated successfully but may require more extensive treatment. Such treatment might include deep cleaning of the tooth root surfaces below the gums, medications prescribed to take by mouth or placed directly under the gums, and sometimes corrective surgery.
To help prevent or control periodontal diseases, it is important to:
- Brush and floss every day to remove the bacteria that cause gum disease.
- See a dentist at least once a year for checkups, or more frequently if you have any of the warning signs or risk factors mentioned above.
Another challenge may be facial paralysis that can cause the tongue, cheek, teeth and gums to be numb. Signorino shared about a recent patient who had a stroke: “He had no feeling on the right side of his face, no feeling on the inside of his cheek, no feeling on his upper and lower teeth and gums. The right side of his tongue was numb. He has to be very careful when he chews food that he doesn’t accidentally bite his tongue or his cheek. He has to check to make sure that he doesn’t have any fractured teeth. If he gets food caught between his teeth, he doesn’t feel it. If he ever had a periodontal abscess or an endodontic abscess, like after a root canal, he wouldn’t know because he wouldn’t experience any pain or discomfort. He has to make sure that he brushes his teeth very well and he’s always rinsing his mouth. He also goes to the dentist and periodontist regularly to make sure he doesn’t have any tooth decay or periodontal disease.”
Rinsing their mouths out by swishing can be a challenge for survivors with facial numbness. “Some people are really not effective at swishing because they can’t pump their cheeks in and out. If you don’t have feeling and you can’t swish, you just do the best you can with your tooth brushing and your flossing. This gentleman puts water in his mouth, tucks his chin to his chest, and puts his head down over the sink and lets the water fall out on that side. A water flosser can also help someone rinse their mouth.”
“I am convinced as a nurse and a hygienist that a person who has good oral hygiene is also investing in good health,” Signorino said. “Good oral hygiene means brushing three or more times a day and flossing at least once a day before bed.”
This information is provided as a resource to our readers. The tips, products or resources listed or linked to have not been reviewed or endorsed by the American Stroke Association.