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The Effectiveness of the Use of "Special Grip Toothbrushes" on Dental Hygiene for Indonesian Patients with Ischemic Stroke

Abstract

Objective:

To find out the effectiveness of specially made brushes with special grips for use by groups of ischemic stroke sufferers for oral hygiene.

Material and Methods:

A sample of 30 stroke patients were taken at the Makassar Stroke Center, Indonesia, with criteria for extreme hemisphere ischemic stroke patients and willing to participate in the study and fill out informed consent. Brush making with a special grip design (modified brush) with Clay mixed material. The oral hygiene assessment procedure of the sample using a modified toothbrush was done in 3 stages before the brush, after brush and on the seventh day. Oral and oral hygiene was measured using the index of Oral Hygiene Index Simplified (OHI-S). The oral hygiene assessment procedure was done in 3 stages before the brush, after brush and on the seventh day. To find out the difference in effectiveness before and after the intervention was analyzed using the paired t-test. The level of significance was set at 5%.

Results:

The highest percentage of stroke patients were female (53.3%), aged 40-60 years (66.7%) with an education level below junior high school (56.7%). There is a difference in the average OHIS score before and after using a special grip toothbrush (p<0.01).

Conclusion:

A special grip toothbrush that is used for Stroke sufferers can help to clean his teeth and mouth.

Keywords:
Cerebrovascular Disorders; Stroke; Oral Hygiene; Dental Devices, Home Care

Introduction

Globally, stroke is the second leading cause of death in people over the age of 60 years and the leading cause of fifth death in people aged 15 to 59 years, common in developing countries [1[1] Yusuf S, Phil D, Rangarajan S, Teo K, Islam S, Li W, Liu L, et al. Cardiovascular risk and events in 17 low-, middle-, and high-income countries. N Engl J Med 2014; 371:818-27. https://doi.org/10.1056/NEJMoa1311890
https://doi.org/10.1056/NEJMoa1311890...

[2] Ahmed AM, Hersi A, Mashhoud W, Arafah MR, Abreu PC, Al Rowaily MA, et al. Cardiovascular risk factors burden in Saudi Arabia: The Africa Middle East Cardiovascular Epidemiological (ACE) study cardiovascular risk factors burden in Saudi Arabia. J Saudi Hear Assoc 2017; 29(4):235-43. https://doi.org/10.1016/j.jsha.2017.03.004
https://doi.org/10.1016/j.jsha.2017.03.0...
-3[3] Şensöz NP, Börü UT, Bölük C, Bilgiç A, Çakmak OO, Duman A, Taşdemire M. Stroke epidemiology in Karabük city Turkey: Community based study. eNeurological Sci 2018, 10:12-5. https://doi.org/10.1016/j.ensci.2017.12.003
https://doi.org/10.1016/j.ensci.2017.12....
]. In Korea, stroke is the third leading cause of death [4[4] Shin H, Park E, Jung E, Kim E, Cho M. The Relationship between oral health and stroke in adults based on the 6th (2015) Korea National Health and Nutrition Examination Survey. J Dent Hyg Sci 2018; 18(1):1-8. https://doi.org/10.17135/jdhs.2018.18.1.1
https://doi.org/10.17135/jdhs.2018.18.1....
]. In China in 2010, stroke has been a major cause of disease and the prevalence of stroke incidence has increased significantly [5[5] Li Q, Wu H, Yue W, Dai Q, Liang H, Bian H, Xia X, Ji Q, Shen Y. Prevalence of stroke and vascular risk factors in China: A nationwide community-based study. Sci Report 2017; 7:6402. https://doi.org/10.1038/s41598-017-06691-1
https://doi.org/10.1038/s41598-017-06691...
]. The prevalence of stroke in Indonesia amounted to 57.9% of the results of the examination and diagnosed health personnel [6[6] Lo HS. Effectiveness of a self-efficacy enhancing stroke self-management program on promoting community-dwelling stroke survivors. [Thesis]. Queensland University of Technology, 2016. Available at: https://eprints.qut.edu.au/99499/. [Accessed on June 18, 2018]
https://eprints.qut.edu.au/99499/...
]. Various factors related to psychological and environmental factors, including time, sex, hypertension, and hyperlipidemia [4[4] Shin H, Park E, Jung E, Kim E, Cho M. The Relationship between oral health and stroke in adults based on the 6th (2015) Korea National Health and Nutrition Examination Survey. J Dent Hyg Sci 2018; 18(1):1-8. https://doi.org/10.17135/jdhs.2018.18.1.1
https://doi.org/10.17135/jdhs.2018.18.1....
].

There are two types of strokes: ischemic and hemorrhagic. Approximately 85% of all strokes are ischemic and 15% hemorrhagic [7[7] Sun H, Zou X, Liu L. Epidemiological factors of stroke: A survey of the current status in China. J Stroke 2013; 15(2):109-14. https://doi.org/10.5853/jos.2013.15.2.109
https://doi.org/10.5853/jos.2013.15.2.10...
,8[8] Stroke Association. State of the Nation. Stroke of Statistics, 2017. Available at: https://www.stroke.org.uk/resources/state-nation-stroke-statistics. [Accessed on July 15, 2018]
https://www.stroke.org.uk/resources/stat...
]. Ischemic stroke is caused by blockage of blood supply to the brain, blockage can be caused by the formation of blood clots in arteries that lead to the brain or one of the small blood vessels present in the brain [9[9] Gopal A. Stroke and oral health. Vital 2008; 5:40-2. https://doi.org/10.1038/vital847
https://doi.org/10.1038/vital847...
] and hemorrhagic stroke caused when blood in the blood vessels burst inside or on the surface of the brain. Because blood leaks into the brain tissue with high pressure, the damage can be greater than the damage caused by a blood clot [10[10] Oral hygiene in adults, United States, 1960-1962. J Am Geriatr Soc 1967; 15(3):310-11. https://doi.org/10.1111/j.1532-5415.1967.tb01146.x
https://doi.org/10.1111/j.1532-5415.1967...
].

Stroke is the second most common cause of disability worldwide in individuals over 60 years; the most common motor dysfunction is hemiparesis because of lesions on the opposite side of the brain. Hemiparesis or weakness on one side of the body is a symptom of motor dysfunction and one type of hemiparesis is dextra hemiparesis which is a weakness or right side paralysis due to damage to the left brain [9[9] Gopal A. Stroke and oral health. Vital 2008; 5:40-2. https://doi.org/10.1038/vital847
https://doi.org/10.1038/vital847...
]. According to previous research stroke patients have a risk of 4 times the occurrence of disability [11[11] Adamson J, Beswick A, Ebrahim S. Is stroke the most common cause of disability? J Stroke Cerebrovasc Dis 2004; 13(4):171-7. https://doi.org/10.1016/j.jstrokecerebrovasdis.2004.06.003
https://doi.org/10.1016/j.jstrokecerebro...
].

Patients with stroke ischemic hemiparesis dextra have problems in grasping, manipulating or controlling toothbrushes, decreasing their effectiveness in using normal manual toothbrushes. So one way that is done to help stroke patients clean the teeth is to make a toothbrush grip that is adjusted to the grip of stroke patients. Modified grips can provide a stable grip for patients to manipulate toothbrushes during cleaning [4[4] Shin H, Park E, Jung E, Kim E, Cho M. The Relationship between oral health and stroke in adults based on the 6th (2015) Korea National Health and Nutrition Examination Survey. J Dent Hyg Sci 2018; 18(1):1-8. https://doi.org/10.17135/jdhs.2018.18.1.1
https://doi.org/10.17135/jdhs.2018.18.1....
,12[12] Alanazi KJ, Subhan SA, Alshehri HM, Aljaload MM, Aljafary MH, Alazmi MA, et al. Influence of tooth brush grips and brushing techniques on plaque removal efficacy. J Dent Oral Health 107; 4:1-7.]. In this study, it was found that stroke patients had oral health status was measured by OHIS index with an average of 4.13. Research has been carried out on various parameters (tooth loss, dental caries experience, and periodontal status) of stroke patients with "bad" conditions [13[13] Dai R, Lam OLT, Lo ECM, Li LSW, Wen Y, McGrath C. A systematic review and meta-analysis of clinical, microbiological, and behavioural aspects of oral health among patients with stroke. J Dent 2015; 43(2):171-80. https://doi.org/10.1016/j.jdent.2014.06.005
https://doi.org/10.1016/j.jdent.2014.06....
].

The oral and dental health of stroke patients is generally poor [14[14] Kwok C, Mcintyre A, Janzen S, Mays R, Teasell R. Oral care post stroke: A scoping review. J Oral RehabIL 2015; 42(1):65-74. https://doi.org/10.1111/joor.12229
https://doi.org/10.1111/joor.12229...
], due to the inability to clean the teeth and mouth, from the results of the study that 83.9% of stroke patients in hospitals have difficulty brushing teeth because it depends on the nurse to maintain health their mouths. Dysphagia is common in stroke patients who increase the risk of xerostomia; therefore, oral health education should be given during their stay in the hospital [15[15] Janket SJ, Baird AE, Chuang SK, Jones JA. Meta-analysis of periodontal disease and risk of coronary heart disease and stroke. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003; 95(5):559-69. https://doi.org/10.1067/moe.2003.107
https://doi.org/10.1067/moe.2003.107...
,16[16] Woon C. Improving oral hygiene for stroke patients. Aust J Neurosci 2017; 27(1):11-3.]. Research using toothbrushes with special handles made of acrylic material [17[17] Kammers ACE, Zanetti AL, Lacerda TSP, Aroca JP, Camilotti V, Mendonça MJ. Toothbrush handles individually adapted for use by elderly patients to reduce biofilm on complete dentures: A pilot study. J Clin Diagnostic Res 2015; 9(5):ZC94-ZC97. https://doi.org/10.7860/JCDR/2015/11261.5975
https://doi.org/10.7860/JCDR/2015/11261....
]. Preparation of special toothbrushes with special handles of acrylic materials by patients has difficulties in processing time, while researchers before conducting research on toothbrushes are specially made from clay material mixed with several easily available ingredients around us [18[18] Pasiga BD. The ability of elderly to clean plaque on full denture prosthesis using toothbrush with special grip design. Int J Dent Med Sci Res 2018; 2(1):22-7.]. Clay material is a material commonly used by children to make models of toys. The results of the study showed that the reduction of plaque on the surface of the dental prosthesis was 13.1%, while the percentage of plaque reduction was 21.2%.

Based on the results of the study of the effects of using a toothbrush with a special handle made of Clay material before, this study aimed to determine the effect of using a modified toothbrush to oral hygiene in stroke patients' ischemic hemiparesis dextra.

Material and Methods

Study Design and Sample

This type of research is a quasi-experiment with one group pre and post-test design. This study was conducted at Makassar Stroke Center where the number of patients treated at Makassar Stroke Center was 91 people and there were 30 stroke patients according to the study criteria. Samples were selected based on the inclusion criteria of Ischemic stroke patients Hemiparesis Dextran; Has at least 10 remaining teeth; Stroke patients who are willing to participate in the study.

Data Collection

Oral and oral hygiene was measured using the index of Oral Hygiene Index Simplified (OHI-S). The OHI-S index or index is used to measure the tooth surface area covered by debris or calculus. For the OHI-S examination, the index teeth used were 4 posterior teeth, 2 anterior teeth. How to assess the OHIS index by measuring the debris index and plaque index on the subject. The degree of oral hygiene clinically in OHI-S can be categorized as follows: Good = (0,0 - 1,2); Medium (1.3 - 3.0); Bad (3,1 - 6,0) [8[8] Stroke Association. State of the Nation. Stroke of Statistics, 2017. Available at: https://www.stroke.org.uk/resources/state-nation-stroke-statistics. [Accessed on July 15, 2018]
https://www.stroke.org.uk/resources/stat...
,10[10] Oral hygiene in adults, United States, 1960-1962. J Am Geriatr Soc 1967; 15(3):310-11. https://doi.org/10.1111/j.1532-5415.1967.tb01146.x
https://doi.org/10.1111/j.1532-5415.1967...
]. Brush making with a special grip design (modified brush) (Figure 1) with Clay mixed material [18[18] Pasiga BD. The ability of elderly to clean plaque on full denture prosthesis using toothbrush with special grip design. Int J Dent Med Sci Res 2018; 2(1):22-7.]. The oral hygiene assessment procedure of the sample using a modified toothbrush was done in 3 stages before the brush, after brush and on the seventh day.

Figure 1
Example of toothbrush made with special grips.

Data Analysis

Data were analyzed using IBM SPSS Statistics for Windows Software, version 24 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to calculate the absolute and relative frequencies, mean and standard deviation. To find out the difference in effectiveness before and after the intervention was analyzed using the paired t-test. The level of significance was set at 5%.

Ethical Aspects

This research has received a recommendation from the Research Ethics Committee of Oral Dental Hospital of the Hasanuddin University of Dentistry, and before conducting prior research the patient or family of patients fill out and sign the informed consent sheet. Permission is also given by the Central Hospital Stroke Makassar.

Results

Table 1 shows the distribution of the sample according to the demographic characteristics. It is possible to observe that the majority were between 40 and 60 years old (66.7%), were female (53.3), did not work (66.7%), the highest level of education is Junior High School graduates (36.7%) and had undergone the stroke between 0 and 4 years (86.7%).

Table 1
Distribution of the sample according to the demographic characteristics.

Table 2 shows the state of pre-treatment dental conditions for the age group 60 years (2.69), male sex (2.65), public servant (2.83), according to the level of education in the group yet finished primary school (2.87) and according to stroke duration in stroke group <4 years (2.78). The highest mean OHIS values for each assessment variables <40 years of age group (4.75), male (4.3), does not work (4.28); by educational level, the uneducated group had the highest OHIS score of 4.74.

Table 2
Average Distribution of CIS, DIS, and OIS values before brushing, after brushing on the first day and after brushing on the seventh day.

Table 3 shows that by age group there was a significant difference in mean OHIS before and after intervention for the 40-60 year group and >60 years group (p<0.001), for the <40 years age group there was no difference in mean score OHIS before and after intervention (p = 0.056). By sex there was a significant difference in mean OHIS values before and after intervention (p<0.001). For groups of occupations (traders, employers and unemployed), there was a significant difference before and after intervention (p<0.001). According to the duration of the stroke, all groups obtained there was a significant difference (p<0.001).

Table 3
The average difference in OHIS values before and after intervention on the first day, and the seventh day.

Figure 2 shows the mean values of DIS, CIS, and OHIS before and after the intervention. The DIS value before the intervention with an average of 2.49 decreased after the intervention to 0.9 and on the seventh day to 0.3. For CIS values, there was no significant decrease from 1.74 to 1.72. For OHIS averages before intervention averaged 4.13 dropped to 2.59 on the first day of intervention and 1.97 on the seventh day.

Figure 2
The average value of debris, calculus and OHIS before and after intervention.

Figure 3 shows the effectiveness of the use of a toothbrush with a special grip obtained a reduction of before and after intervention on the first day for DIS of 51.54%, before and after the intervention of the seventh day to 89.23%. To reduce the percentage of OHIS value by 45% after the first-day intervention and rise to 52.2% on the seventh day.

Figure 3
Percentage reduction of debris, calculus and OHIS before and after.

Figure 4 shows the state of oral hygiene of stroke patients before and after the intervention. Circumstances before the intervention where the "bad" oral hygiene status of 86.6% decreased to 10% after using a special toothbrush; while the "moderate" status before only 13.3%, after intervention increased to 73.3%.

Figure 4
Distribution of percentage of oral hygiene status before and after treatment.

Discussion

The samples used in this study were stroke ischemic hemiparesis dextra patients, due to problems of grasping, manipulating or controlling toothbrushes, decreasing the effectiveness of using normal manual toothbrushes.

Handling stroke patients for their survival is highly competitive services of high quality. The dental team is part of a multidisciplinary approach to the treatment of stroke patients. The role of the dental team is to advise and assist care services in maintaining proper oral health during the early stages after a stroke [19[19] British Society of Gerodontology. Guidelines for the Oral Healthcare of Stroke Survivors, 2010. Available at: https://www.gerodontology.com/content/uploads/2014/10/stroke_guidelines.pdf. [Accessed on June 18, 2018]
https://www.gerodontology.com/content/up...
].

Oral hygiene management for people with stroke is very important because it is known that the oral hygiene of stroke patients is so that it can increase the prevalence of oral disease. It can cause dry mouth, mouth ulcers, and stomatitis, thus adding to the poor oral health of stroke patients. Based on the results of a meta-analysis showing the relationship between periodontitis and ischemic stroke [20[20] Leira Y, Seoane J, Blanco M, Rodríguez-Yáñez M, Takkouche B, Blanco J, et al. Association between periodontitis and ischemic stroke: A systematic review and meta-analysis. Eur J Epidemiol 2017; 32(1):43-53. https://doi.org/10.1007/s10654-016-0170-6
https://doi.org/10.1007/s10654-016-0170-...
]. Therefore, maintenance and promotion of oral health of stroke patients are important factors.

Generally, dental and oral hygiene factors are poorly addressed by the health care workers, and the treatment of stroke patients [6[6] Lo HS. Effectiveness of a self-efficacy enhancing stroke self-management program on promoting community-dwelling stroke survivors. [Thesis]. Queensland University of Technology, 2016. Available at: https://eprints.qut.edu.au/99499/. [Accessed on June 18, 2018]
https://eprints.qut.edu.au/99499/...
,14[14] Kwok C, Mcintyre A, Janzen S, Mays R, Teasell R. Oral care post stroke: A scoping review. J Oral RehabIL 2015; 42(1):65-74. https://doi.org/10.1111/joor.12229
https://doi.org/10.1111/joor.12229...
,21[21] Lam OLT, McMillan AS, Li LSW, McGrath C. Predictors of oral health-related quality of life in patients following stroke. J Rehabil Med 2014; 46(6):520-6. https://doi.org/10.2340/16501977-1806
https://doi.org/10.2340/16501977-1806...
]. The highest prevalence of stroke patients is a group of people who do not work (66.7%). This group is found in many developing regions. It is suspected that the cause of this group stroke is stress or depression. If grouped based on Family Development Index (FDI), including people with the very severe category. The results of research conducted in Bau-Bau Indonesia were obtained equal to 83.3%, so they really needed to be given special attention in maintaining their health [22[22] Pasiga BD, Samad R, Pratiwi R. Socio-dental and family living condition approach for planning dental care: A cross-sectional study among Indonesian students. Pesqui Bras Odontopediatria Clín Integr 2018; 18(1):e4028. https://doi.org/10.4034/PBOCI.2018.181.81
https://doi.org/10.4034/PBOCI.2018.181.8...
].

The results of this study are in line with other studies which state that modified toothbrushes can significantly reduce the amount of dental plaque, in addition to other studies on the ability of parents to clean plaques on full denture prostheses with special toothbrush designs that suggest a decrease 21.8% plaque accumulation compared to conventional toothbrushes of 14.2% [4[4] Shin H, Park E, Jung E, Kim E, Cho M. The Relationship between oral health and stroke in adults based on the 6th (2015) Korea National Health and Nutrition Examination Survey. J Dent Hyg Sci 2018; 18(1):1-8. https://doi.org/10.17135/jdhs.2018.18.1.1
https://doi.org/10.17135/jdhs.2018.18.1....
]. The presence of plaque from poor oral hygiene can lead to decreased salivary deficits of stroke disease [16[16] Woon C. Improving oral hygiene for stroke patients. Aust J Neurosci 2017; 27(1):11-3.].

Other studies also say that 89.3% of stroke patients have difficulty in maintaining their own teeth due to illness and inability to communicate on their own and relying on nurses or family families to maintain oral health [14[14] Kwok C, Mcintyre A, Janzen S, Mays R, Teasell R. Oral care post stroke: A scoping review. J Oral RehabIL 2015; 42(1):65-74. https://doi.org/10.1111/joor.12229
https://doi.org/10.1111/joor.12229...
]. Special attention is needed for stroke sufferers other than making special grips as well as how to store toothbrushes, either using chemical solutions or using ultraviolet sanitizing tools [23[23] Pasiga BD. Effectiveness of use of ultraviolet sanitizing devices for reduction of bacterial colonies on toothbrushes. Int J Med Dent Sci 2018; 7(2):1676-83. https://doi.org/10.18311/ijmds/2018/20073
https://doi.org/10.18311/ijmds/2018/2007...
].

The modified toothbrush is a conventional toothbrush enlarged in accordance with the handle of each individual. The material used to enlarge the toothbrush handle is clay. Clay is a material that is easy to obtain, easy to form, and can dry if on the go so that the manufacturing process is not difficult. This modified toothbrush is aimed at individuals who have limited motor in grasping and using toothbrushes. Increasing the volume of the toothbrush handle can stabilize the grip making it easier for the individual to control and use a toothbrush. The use of this modification toothbrush can be reserved for those who have motor limitations such as children with special limitations. The results of this study are also in accordance with other studies, which state that the ability of "mentally handicapped" children at 12 years is lower than the age of normal children so that "mentally handicapped" children have difficulty in holding and using toothbrush [24[24] Martens L, Marks L, Goffin G, Gizani S, Vinckier F, Declerck D. Oral hygiene in 12-year-old disabled children in Flanders, Belgium, related to manual dexterity. Community Dent Oral Epidemiol 2000; 28(17):73-80. https://doi.org/10.1034/j.1600-0528.2000.280110.x
https://doi.org/10.1034/j.1600-0528.2000...
].

Conclusion

The percentage of oral hygiene status of stroke patients with "bad" condition is high and after using special toothbrush can raise the "good" status to be higher, so based on the results it can be concluded that individual toothbrush with special grip effective in reducing oral hygiene of stroke patient ischemic.

  • Financial Support: None.

Acknowledgments:

To the Director of Makassar Stroke Center for giving permission to conduct research and also to the students of the Faculty of Dentistry, Hasanuddin University, the level of professions that assist in conducting research.

References

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    Yusuf S, Phil D, Rangarajan S, Teo K, Islam S, Li W, Liu L, et al. Cardiovascular risk and events in 17 low-, middle-, and high-income countries. N Engl J Med 2014; 371:818-27. https://doi.org/10.1056/NEJMoa1311890
    » https://doi.org/10.1056/NEJMoa1311890
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    Ahmed AM, Hersi A, Mashhoud W, Arafah MR, Abreu PC, Al Rowaily MA, et al. Cardiovascular risk factors burden in Saudi Arabia: The Africa Middle East Cardiovascular Epidemiological (ACE) study cardiovascular risk factors burden in Saudi Arabia. J Saudi Hear Assoc 2017; 29(4):235-43. https://doi.org/10.1016/j.jsha.2017.03.004
    » https://doi.org/10.1016/j.jsha.2017.03.004
  • [3]
    Şensöz NP, Börü UT, Bölük C, Bilgiç A, Çakmak OO, Duman A, Taşdemire M. Stroke epidemiology in Karabük city Turkey: Community based study. eNeurological Sci 2018, 10:12-5. https://doi.org/10.1016/j.ensci.2017.12.003
    » https://doi.org/10.1016/j.ensci.2017.12.003
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    Shin H, Park E, Jung E, Kim E, Cho M. The Relationship between oral health and stroke in adults based on the 6th (2015) Korea National Health and Nutrition Examination Survey. J Dent Hyg Sci 2018; 18(1):1-8. https://doi.org/10.17135/jdhs.2018.18.1.1
    » https://doi.org/10.17135/jdhs.2018.18.1.1
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    Li Q, Wu H, Yue W, Dai Q, Liang H, Bian H, Xia X, Ji Q, Shen Y. Prevalence of stroke and vascular risk factors in China: A nationwide community-based study. Sci Report 2017; 7:6402. https://doi.org/10.1038/s41598-017-06691-1
    » https://doi.org/10.1038/s41598-017-06691-1
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    Lo HS. Effectiveness of a self-efficacy enhancing stroke self-management program on promoting community-dwelling stroke survivors. [Thesis]. Queensland University of Technology, 2016. Available at: https://eprints.qut.edu.au/99499/ [Accessed on June 18, 2018]
    » https://eprints.qut.edu.au/99499/
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    Sun H, Zou X, Liu L. Epidemiological factors of stroke: A survey of the current status in China. J Stroke 2013; 15(2):109-14. https://doi.org/10.5853/jos.2013.15.2.109
    » https://doi.org/10.5853/jos.2013.15.2.109
  • [8]
    Stroke Association. State of the Nation. Stroke of Statistics, 2017. Available at: https://www.stroke.org.uk/resources/state-nation-stroke-statistics [Accessed on July 15, 2018]
    » https://www.stroke.org.uk/resources/state-nation-stroke-statistics
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    Gopal A. Stroke and oral health. Vital 2008; 5:40-2. https://doi.org/10.1038/vital847
    » https://doi.org/10.1038/vital847
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    Oral hygiene in adults, United States, 1960-1962. J Am Geriatr Soc 1967; 15(3):310-11. https://doi.org/10.1111/j.1532-5415.1967.tb01146.x
    » https://doi.org/10.1111/j.1532-5415.1967.tb01146.x
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    Adamson J, Beswick A, Ebrahim S. Is stroke the most common cause of disability? J Stroke Cerebrovasc Dis 2004; 13(4):171-7. https://doi.org/10.1016/j.jstrokecerebrovasdis.2004.06.003
    » https://doi.org/10.1016/j.jstrokecerebrovasdis.2004.06.003
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    Alanazi KJ, Subhan SA, Alshehri HM, Aljaload MM, Aljafary MH, Alazmi MA, et al. Influence of tooth brush grips and brushing techniques on plaque removal efficacy. J Dent Oral Health 107; 4:1-7.
  • [13]
    Dai R, Lam OLT, Lo ECM, Li LSW, Wen Y, McGrath C. A systematic review and meta-analysis of clinical, microbiological, and behavioural aspects of oral health among patients with stroke. J Dent 2015; 43(2):171-80. https://doi.org/10.1016/j.jdent.2014.06.005
    » https://doi.org/10.1016/j.jdent.2014.06.005
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    Kwok C, Mcintyre A, Janzen S, Mays R, Teasell R. Oral care post stroke: A scoping review. J Oral RehabIL 2015; 42(1):65-74. https://doi.org/10.1111/joor.12229
    » https://doi.org/10.1111/joor.12229
  • [15]
    Janket SJ, Baird AE, Chuang SK, Jones JA. Meta-analysis of periodontal disease and risk of coronary heart disease and stroke. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003; 95(5):559-69. https://doi.org/10.1067/moe.2003.107
    » https://doi.org/10.1067/moe.2003.107
  • [16]
    Woon C. Improving oral hygiene for stroke patients. Aust J Neurosci 2017; 27(1):11-3.
  • [17]
    Kammers ACE, Zanetti AL, Lacerda TSP, Aroca JP, Camilotti V, Mendonça MJ. Toothbrush handles individually adapted for use by elderly patients to reduce biofilm on complete dentures: A pilot study. J Clin Diagnostic Res 2015; 9(5):ZC94-ZC97. https://doi.org/10.7860/JCDR/2015/11261.5975
    » https://doi.org/10.7860/JCDR/2015/11261.5975
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    Pasiga BD. The ability of elderly to clean plaque on full denture prosthesis using toothbrush with special grip design. Int J Dent Med Sci Res 2018; 2(1):22-7.
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    British Society of Gerodontology. Guidelines for the Oral Healthcare of Stroke Survivors, 2010. Available at: https://www.gerodontology.com/content/uploads/2014/10/stroke_guidelines.pdf [Accessed on June 18, 2018]
    » https://www.gerodontology.com/content/uploads/2014/10/stroke_guidelines.pdf
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    Leira Y, Seoane J, Blanco M, Rodríguez-Yáñez M, Takkouche B, Blanco J, et al. Association between periodontitis and ischemic stroke: A systematic review and meta-analysis. Eur J Epidemiol 2017; 32(1):43-53. https://doi.org/10.1007/s10654-016-0170-6
    » https://doi.org/10.1007/s10654-016-0170-6
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Edited by

Academic Editors: Alessandro Leite Cavalcanti and Wilton Wilney Nascimento Padilha

Publication Dates

  • Publication in this collection
    10 Oct 2019
  • Date of issue
    2019

History

  • Received
    21 Aug 2018
  • Accepted
    15 Jan 2019
  • Published
    23 Jan 2019
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