Kelly T et al (2010) Review of the evidence to support oral hygiene in stroke patients. Nursing Standard. 24, 37, 35-38. Date of acceptance: March 16 2010.

�Assessment of oral hygiene should be carriedout using a validated tool.

�Care should be carried out using best practice.

�Assistance should be provided based onindividual need.

�Patients should be given information andeducation to enable them to meet their oralhygiene needs.

Whether nurses care for patients in a high-dependency unit, a general medical ward or ina nursing home, they have a duty of care to ensure a good standard of oral hygiene for patients. Forthose patients who have had a stroke, oral care may have added complexities because of spatialproblems, cognitive impairment, poor sittingbalance and upper limb weakness. The increase in yeasts may increase the incidence of aspirationpneumonia and oral Candida (Zhu et al2008). The National Clinical Guideline for Stroke(Intercollegiate Stroke Working Party 2008) setsout specific guidance for the provision of good oralhygiene for patients who have had a stroke (Box 2).

Oral hygiene practices

Oral hygiene is a core nursing role, however there is evidence that nurses view it as a low priority(Wårdh et al2000). Some nurses demonstrate poorknowledge of oral hygiene practices (Preston et al2000, White 2000) and, in some circumstances,may use outdated tools, relying on tradition andpractices passed down from one generation ofnurses to the next (McKenna et al2000, Pearsonand Hutton 2002). McAuliffe (2007) highlighteda paucity of oral hygiene education for nursingstudents with most of the learning taking place in the ward environment. There is also evidence

Review of the evidence to supportoral hygiene in stroke patients

may 19 :: vol 24 no 37 :: 2010 35NURSING STANDARD

THERE IS A CONSENSUS in general nursingliterature that providing good oral hygiene (mouthcare) for patients in hospital is an essential aspect of nursing care. Yet wide variations in clinicalpractice exist. This article presents a literaturereview on oral hygiene (Box 1), focusing on the care of patients with stroke.

The importance of good oral hygiene ishighlighted in the literature: ‘the person’s comfort,good nutrition, and general wellbeing are promotedby maintaining clean and well-cared-for teeth andgums’ (Nettina 2006). The Essence of Carebenchmark for personal and oral hygiene states that (Department of Health (DH) 2001):

SummaryMaintaining good oral hygiene in patients who have had a stroke isan essential part of care. This literature review highlights the poorprovision of such care in acute medical and rehabilitation settings. It reveals a lack of evidence for current practices and suggests that research may be helpful in defining which nursing interventionsare most effective.

AuthorsTerence Kelly, education and development practitioner, and Sally Timmis, stroke specialist nurse, Central Manchester UniversityHospitals NHS Foundation Trust; Timothy Twelvetree, research fellow,The University of Manchester and Central Manchester UniversityHospitals NHS Foundation Trust. Email: terence.kelly@cmft.nhs.uk

KeywordsNursing care, oral hygiene, rehabilitation, research, strokeThese keywords are based on subject headings from the BritishNursing Index. All articles are subject to external double-blind peerreview and checked for plagiarism using automated software. Forauthor and research article guidelines visit the Nursing Standardhome page at www.nursing-standard.co.uk. For related articlesvisit our online archive and search using the keywords.

If you would like to contribute to the art and science section contact: Gwen Clarke, art and science editor, Nursing Standard, The Heights, 59-65 Lowlands Road, Harrow-on-the-Hill, Middlesex HA1 3AW. email: gwen.clarke@rcnpublishing.co.uk

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knowledge related to oral hygiene amongregistered nurses, that untrained healthcareassistants carry out a substantial amount of oralhygiene, and that it is deemed a low prioritywhen staffing levels are low.

Fitzpatrick (2000) reached similarconclusions in a review of the literature on theoral hygiene needs of dependent older people in continuing care settings and theresponsibilities of nursing and healthcare staff.Nurses’ knowledge of oral hygiene wasvariable and there was an absence of a validand reliable assessment tool. Fitzpatrick (2000)recommended revisiting the educationalpreparation of pre and post-registration staff.In a survey of nurses in Ireland, Costello andCoyne (2008) reported that some nurses lackedknowledge of oral care procedures, and hadlimited access to assessment tools and to thecorrect equipment needed.

Oral hygiene provided on stroke units appearsto mirror that in other care settings. Talbot et al(2005) conducted a postal survey of wardmanagers and senior nurses on stroke unitsthroughout Scotland. The survey had excellentresponse rates, with familiar themes emerging.There were large variations in care, with only one third of staff receiving oral care training.There was limited use of oral assessment toolsand, in some areas, a lack of toothbrushes andtoothpaste to carry out care.

To provide good oral hygiene, many studiesrecommend educating staff, using equipmentthat has a sound evidence base and adhering to validated oral hygiene assessment and careguidelines (Roberts 2000a, Pearson and Hutton2002, Allen Furr et al 2004).

Interventions to improve oral hygiene

Brady et al (2006) carried out a review tocompare the effectiveness of staff-led oralhygiene interventions with the standard care of oral hygiene for individuals followingstroke. The conclusions of this review illustratethe gaps in research knowledge and help to explain the wide variations that exist in clinical practice.

The review examined randomised controlledtrials that evaluated one or more interventionsdesigned to improve the oral hygiene of patientsdiagnosed with stroke and requiring assistancewith oral hygiene. From more than 8,000references initially sourced for the review, onlyeight were deemed eligible for inclusion. Seven ofthese trials were eliminated as they did not provideinformation specific to individuals followingstroke. One particular trial that met the inclusioncriteria evaluated an oral hygiene educationtraining programme delivered to nursing home

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BOX 1

Results of the literature review

The literature review included an examination of:

�A total of 11 research studies, of which:– Two used an experimental design.– Nine used a survey approach.

�A total of 11 literature and clinical practice reviews.

Databases searched included:

�Cumulative Index of Nursing and Allied Health Literature (CINAHL).

�Medline (1995-2008: the date range refers to the time period betweenthe acute stroke unit at Manchester Royal Infirmary being set up andthe last year of available data before study commencement).

�Guideline registers from the National Institute for Health and ClinicalExcellence.

�The Scottish Intercollegiate Guidelines Network (SIGN).

�Trial registers of the Cochrane Stroke Group and Oral Health Group.

A full list of reviewed literature and search terms is available from theauthors, on request.

All patients who are not swallowing, including those receiving tube feeding,should have oral and dental hygiene maintained (by the patient or carers)through regular (four hourly):�Brushing of teeth, dentures and gums with a suitable cleaning agent,

for example, toothpaste or chlorhexidine gluconate dental gel.�Removal of secretions.

All patients with dentures should have them:�Put in appropriately during the day.�Cleaned regularly.�Checked and, where necessary, replaced by a dentist if ill-fitting,

damaged or lost.

All patients with swallowing difficulties and/or facial weakness who aretaking food orally should be taught or helped to clean their teeth or dentures after each meal.

Staff or carers responsible for the care of patients disabled by stroke (in hospital, residential or home settings) should be trained in:�Assessment of oral hygiene.�Selection and use of appropriate oral hygiene equipment and cleaning

agents.�Provision of oral hygiene routines.�Recognition and management of swallowing difficulties.

(Intercollegiate Stroke Working Party 2008)

BOX 2

Guidance on oral hygiene interventions

to suggest that nurses perceive oral hygiene to bean unpleasant task (Allen Furr et al 2004).

Using a questionnaire approach to investigateregistered nurses’ approach to oral care forpatients on medical wards, Adams (1996)concluded that there is a lack of general

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care assistants (Frenkel et al2001). Of the 412residents recruited from the 22 nursing homes, 67 had a history of stroke (Frenkel et al2001).Considering that there are more than 900,000people living with stroke in England alone(Intercollegiate Stroke Working Party 2008), theneed for more research into the oral hygiene needsof this group of patients is apparent.

Frenkel et al (2001) divided care assistants intoan intervention group that received training andan oral hygiene care booklet, and a control groupproviding standard care, but that received thetraining intervention following completion of thetrial. Training sessions focused on the role plaqueplays in oral disease and a practical session oncleaning techniques for natural teeth and dentures.A comprehensive tool to assess oral hygiene wasused in the study as part of data collection.

Results suggested that the knowledge andattitudes of the staff in the intervention group ofcarers were, respectively, higher and improved atboth one and six months, compared with thecontrol group. This in itself should be deemed asuccess in light of the literature indicating thatnurses view oral hygiene as a low priority, havepoor knowledge on the subject and perceive oralhygiene to be an unpleasant task (Preston et al2000, Wårdh et al 2000, White 2000, Allen Furret al 2004).

Residents with dentures who received theintervention had less plaque on their denturesat both one and six months. Gingivitis was less common in the intervention group at six months compared with residentsreceiving only standard care (Frenkel et al2001). The authors suggested that althoughthere was an improvement in the interventiongroup’s oral hygiene, the ‘persistence of highdental plaque scores seems to reflect the greater reluctance of caregivers to carry out intra-oral hygiene for another person’ (Frenkel et al 2001).

A similar study by Paulsson et al (2008)measured the effect of an oral hygiene programmefor nursing personnel in special housing facilitiesfor older people. Knowledge assessment wasundertaken using a questionnaire, and the resultssuggested that knowledge was retained threeyears after the initial training.

The work by Frenkel et al (2001) andPaulsson et al (2008) focused on care assistantsworking in nursing homes. It could be suggestedthat this does not provide insight into theprovision of care in an acute hospital. However,it is important to recognise that a large amountof personal and oral hygiene care is carried outby clinical support workers in hospitals. Adams (1996) found that non-registered staff performed a substantial amount ofpatients’ oral hygiene.

Frenkel et al’s (2001) study suggests that the provision of an education programme canhave a positive effect on the knowledge andattitudes of healthcare staff and a beneficialeffect on patients’ oral hygiene. However, thissuccessful outcome was an isolated finding inBrady et al’s (2006) review, which concludedthat ‘there is a paucity of high quality evidencerelating to oral healthcare interventions forindividuals after stroke’. The authors alsodiscussed the nature of the specificrehabilitative role that oral hygiene can have inthe stroke setting and were disappointed thatnone of the literature acknowledged this role(Brady et al 2006).

Discussion

The main findings in the literature in relation to oral care provision for patients in generalhospital settings are summarised in Box 3. The findings can be grouped into three headings:attitude and organisation, evidence and tools,and education and training.Attitude and organisation Much of the oralhygiene given to patients is undertaken by non-registered staff. Oral hygiene is given a low priority by registered nurses (Adams 1996,Fitzpatrick 2000, Wårdh et al 2000).Evidence and tools There is a lack of empiricalevidence to support which nursinginterventions are effective in maintaining goodoral hygiene (Brady et al 2006). There isevidence to suggest toothbrushes are the mosteffective tool for maintaining good oralhygiene, but the use of foam sticks remainsprevalent (Pearson and Hutton 2002). Thereare a number of examples of oral hygiene

may 19 :: vol 24 no 37 :: 2010 37NURSING STANDARD

�Some nurses perceive oral hygiene care to be an unpleasant task.

�Oral hygiene care is a low priority for many registered nurses.

�Non-registered staff perform a substantial proportion of oral hygiene tasks.

�There is a lack of empirically tested, reliable and validated assessmenttools for oral hygiene.

�The equipment used to perform oral hygiene is frequently inappropriate, despite evidence to suggest the use of toothbrushes is an effective tool.

�Limited evidence suggests that toothbrushes are substantially moreeffective than foam swabs at removing dental plaque.

�There is a lack of evidence to support current oral hygiene practices.

�There is little education for nurses on oral hygiene, at undergraduate level or as part of continuing professional development programmes.

�There is limited evidence that education improves nurses’ knowledge and attitudes to oral care and has a positive effect on oral hygiene.

BOX 3

Oral hygiene in the hospital setting: main findings

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assessment tools being developed, which maybe effective (Roberts 2000a, 2000b and2000c), but there is no empirical evidence oftheir sustained effectiveness.Education and training Education programmesthat improve nurses’ knowledge of oral hygienecare may have positive benefits (Frenkel et al2001, Paulsson et al 2008). However, educationon assessing oral hygiene needs and planningand implementing care is limited in continuingprofessional development programmes (Talbotet al 2005, Stout et al 2009). There is also a lackof formal education on oral hygiene forundergraduate nursing students, with studentsbeing exposed to outdated practices on wards(McAuliffe 2007).

It is important to recognise that there is much good published work by nurses aiming to improve the oral care of patients (Huskinsonand Lloyd 2009, Malkin 2009). The Essence ofCare benchmark for personal and oral hygiene(DH 2001) could, if used correctly, assist in improving oral hygiene by providing a benchmark for care and encouraging staff to share good practice.

Conclusion

This literature review shows the limited evidenceon the effectiveness of interventions in oral hygienecare is focused on the use of toothbrushes andeducation programmes. Further research needs tobe carried out in the acute hospital setting. Forstroke patients in particular, research needs to:

�Be undertaken in acute and rehabilitationstroke settings.

�Establish the effectiveness of otherinterventions to improve oral hygiene care, such as validating assessment tools and oral hygiene training for patients.

�Show that the effectiveness of integrating oral hygiene goals into a rehabilitationprogramme in stroke units is worthy of further research.

�Develop an evidence base for oral careinterventions.

There is limited evidence that education canchange healthcare staff’s knowledge and attitudeto improve oral hygiene. The challenge is todevelop an evidence base that defines the nursinginterventions that improve oral hygiene,particularly for stroke patients NS

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