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A stroke takes place when the blood supply to the brain is blocked or when a blood vessel in the brain ruptures, causing brain tissue to die.1 It can happen to anyone at any time, no matter what gender, age, or race. In the United States, stroke is the fourth leading cause of death, killing over 133,000 people a year. There are an estimated 7 million survivors of stroke, which is the principal cause of serious long-term adult disability.2 Brain damage from a stroke causes many physical and psychosocial changes in the patient. While every stroke is unique, it tends to affect people in common ways.
Physical Effects and Considerations
When someone has a stroke, the functions that are affected depend upon which area of the brain was damaged and how much damaged occurred.2 Because one side of the brain affects the opposite side of the body, a stroke will result in neurological complications on the side of the body opposite the side of the brain affected; that is, a stroke on the left side of the brain will affect the right side of the body, possibly producing right side paralysis and speech and language problems. Some of the many possible physical effects of a stroke are listed below:
Common Physical Considerations Following a Stroke3,4
• Aphasia: Difficulty understanding or using language.
• Apraxia: Trouble producing purposeful gestures despite understanding and physical ability. Oral apraxia impairs voluntary movement of the oral/respiratory structures, such as tongue protrusion, expectorating, blowing, or puckering the lips.
• Aspiration: Inhaling food into the airway.
• Balance disturbances: Dizziness or a spinning sensation associated with an increase in falls.
• Central post-stroke pain: Chronic condition caused by injury to the central nervous system. Patients may not feel any sensation in limbs when touched but can feel constant pain.
• Dementia: Severe mental deterioration involving impairment of mental ability.
• Disturbed vision: Double vision or loss of vision in one eye.
• Dysphagia: Difficulty swallowing.
• Facial palsy: Facial nerve paralysis.
• Foot drop: Inability to raise the front part of the foot because of weakness or paralysis of the muscle that normally lifts the foot.
• Hemiparesis: Loss of movement and feeling on one side of the body.
• Paraparesis: Loss of movement and feeling on both sides of the body.
• Predisposition to bleeding: Anticoagulant medications prescribed to the patient who has had a stroke predispose the patient to bleeding.
• Post-stroke fatigue: Tiredness, weakness, and overall decreased endurance.
• Shoulder subluxation: Separated shoulder.
• Weakness of the facial and oral motor area: Open slack jaw posture and poor control of oral secretions.
• Risk of another stroke: Having a stroke means greater risk for another stroke.
• Xerostomia: Susceptibility to dry mouth caused by medications.
Psychosocial Effects and Considerations
After a stroke, people often experience emotional and behavioral changes. This is because stroke affects the brain, and our brain controls our behavior and emotions. Not only can a stroke impact mood and outlook, but chemical changes result from the brain injury.5 The patient–dental hygienist relationship may be altered dramatically by changes in the patient’s lifestyle, abilities, and self-perception.
Common Psychosocial Considerations Following a Stroke5
• Anxiety, egocentricity and rigidity: Desperate need to regain sense of control, demands for attention, exaggerated responses to the need to re-establish predictability in their lives.
• Depression: Symptoms of major depression include sadness, anxiety/restlessness, loss of energy, decreased appetite and weight loss, insomnia, social withdrawal, and irritability.
• Feelings of grief and loss: Denial, anger, depression, and bargaining before arriving at the stage of acceptance.
• Learned helplessness: Feeling completely powerless to change one’s circumstances for the better; a coping mechanism as result of severe depression, and extremely low-self-esteem.
• Memory deficits: Inability to retain new data or recall old information.
Dental Hygiene Management
The first post-stroke appointment is not usually recommended until 6 months after a stroke.4 Furthermore, prior information from the patient, patient’s physician, family caregiver, and other members of the healthcare rehabilitation team will determine the patient’s status and advisability of proceeding with dental hygiene treatment. At the time of treatment, the patient must be able to make an informed and consensual decision or have the caregiver consent on their behalf. The stroke patient’s ability to comprehend may be compromised due to aphasia or cognitive impairment. Therefore, the primary caregiver or other office staff should be present to validate adequate comprehension and consent. That said, referring to the caregiver for consent too quickly undermines the patient’s right to autonomy, so caution is indicated.4 Below is a list that offers the dental hygienist many clinical chairside tips for working with the stroke patient once it has been determined that care may begin:
Stroke Patient Dental Hygiene Management Clinical Tips3,4,6
• Hemiparesis patients may walk with a cane or walker or use a wheelchair. It may be necessary to assist the patient into the office and to transfer the patient from a wheelchair to treatment chair.
• Monitor blood pressure: it should be 140/90 or under.
• Recent INR range should be 1.5–3.5.
• Patients may need adaptive products for oral hygiene care. They also may need to learn to clean dentures using one hand, which is especially difficult if the dominant hand is weakened or paralyzed.
• Weakness of the facial and oral motor area may induce a gag reflex that requires cautionary measures during dental treatment.
• Dysphagic patients and their caregivers should receive special attention concerning a vigilant oral hygiene program due to the tendency to pocket food, the increased risk of infection and caries, and the danger of aspiration. You may want to check with a speech language pathologist to receive advice about a particular head position that facilitates the patient’s ability to swallow.
• Add at least 5 to 10 minutes to the procedure time, as medical history updates, explanations and oral hygiene instruction may take longer.
• Set short-term, easily attainable goals to increase self-efficacy related to oral hygiene care.
• Recognize the signs and symptoms of a subsequent stroke and train for emergency management.
After a stroke, many survivors face communication challenges, whether difficulty speaking, understanding words spoken by others, reading, writing, and math skills.7 Most stroke survivors can improve their ability to communicate, but the degree of improvement is unpredictable. Dental hygienists have a special challenge providing quality care while lessening the patient’s stress and supporting the best communication. Below are some useful techniques to use when communicating with a patient who has had a stroke:
Communication Strategies for the Dental Hygienist Working with a Stroke Survivor4,7
• Use a slow, deliberate pattern of speech delivered at eye level.
• Address the patient from the unimpaired side of the body.
• Reduce visual and auditory distraction, maintain a smooth quiet office routine and avoid devices that create a high level of background noise, such as the ultrasonic scaler.
• Regain lost attention by establishing eye contact, touching the patient gently, and saying the patient’s name.
• Be cautious about relying on the patient’s yes or no response as aphasia can cause patients to confuse the two terms.
• Allow more time for the patient to think about or respond to questions.
• Be patient but not patronizing.
An Interdisciplinary Approach
The holistic, comprehensive, interactive approach of an interdisciplinary team is the hallmark of stroke rehabilitation. With collaborative input from all rehabilitation participants, including stroke survivors and their family, comprehensive and individualized assessment and treatment plans are devised.8 Members of the interdisciplinary team may include, but are not limited to the following professionals: nurses, physicians, physiotherapists, occupational therapists, certified rehabilitation counselors, neuropsychologists, recreation therapists, social workers, and speech language pathologists. Dental hygienists can be active participants in their patients’ stroke prevention or rehabilitation, as they may be one of the few providers who see the patient regularly. Accordingly, dental hygienists should be familiar with the variety of services and procedures provided by other disciplines that are central to the stroke rehabilitation.
An example of an interdisciplinary approach may be a dental hygienist contacting a speech language pathologist when working with a patient afflicted with oral apraxia; perhaps because tooth brushing has become difficult due to tongue protrusion and expectoration. The speech language pathologist can assist with the analysis of oral motor tasks. Collectively, the patient–caregiver–dental hygienist–speech language pathologist can work together to improve the oral and overall health of the patient.
A stroke’s impact on physical and psychosocial changes can be far-reaching and difficult. Being prepared for a stroke patient requires a thorough knowledge of the changes that can occur and perceptive understanding of how to address, improve, or work around them.
1. Centers for Disease Control and Prevention. Stroke. Available at: www.cdc.gov/stroke/index.htm.
2. American Heart Association and American Stroke Association. Effects of stroke. Available at: www.strokeassociation.org/STROKEORG/AboutStroke/EffectsofStroke/Effects-of-Stroke_UCM_308534_SubHomePage.jsp.
3. American Heart Association and American Stroke Association. Physical challenges after stroke. Available at: www.strokeassociation.org/STROKEORG/LifeAfterStroke/RegainingIndependence/PhysicalChallenges/Physical-Challenges-After-Stroke_UCM_308548_SubHomePage.jsp.
4. Ostuni E. Stroke and the dental patient. J Am Dent Assoc. 1994;125(6):721-727.
5. American Heart Association and American Stroke Association. Emotional and behavioral challenges after stroke. Available at: www.strokeassociation.org/STROKEORG/LifeAfterStroke/RegainingIndependence/EmotionalBehavioralChallenges/Emotional-and-Behavioral-Challenges-After-Stroke_UCM_308549_SubHomePage.jsp.
6. Bui L. A summary of current perspectives on dental procedures in anticoagulated patients. Available at: http://stanfordhospital.org/PDF/anticoagulation/dentalProcedure.pdf.
7. American Heart Association and American Stroke Association. Communication challenges after stroke. Available at: www.strokeassociation.org/STROKEORG/LifeAfterStroke/RegainingIndependence/CommunicationChallenges/Communication-Challenges-After-Stroke_UCM_308550_SubHomePage.jsp
8. Miller E, Murray L, Richards L et al. Comprehensive overview of nursing and interdisciplinary rehabilitation care of the stroke patient: a scientific statement from the American Heart Association. Stroke. 2010;41(10):2402-2448.
About the Author
Andrea Beall, RDH, MA, is a part-time clinical assistant professor at New York University College of Dentistry and a doctoral candidate at Columbia University. She has practiced dental hygiene for over 20 years and has worked in Canada, Switzerland and the United States.