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If you would like to contribute to the art and science section contact: Gwen Clarke, art and science editor, Nursing Standard,
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Review of the evidence to support

oral hygiene in stroke patients
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.

Summary
Maintaining good oral hygiene in patients who have had a stroke is
an essential part of care. This literature review highlights the poor
provision 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 interventions
are most effective.

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

Keywords
Nursing care, oral hygiene, rehabilitation, research, stroke
These keywords are based on subject headings from the British
Nursing Index. All articles are subject to external double-blind peer
review and checked for plagiarism using automated software. For
author and research article guidelines visit the Nursing Standard
home page at www.nursing-standard.co.uk. For related articles
visit our online archive and search using the keywords.

THERE IS A CONSENSUS in general nursing

literature that providing good oral hygiene (mouth
care) for patients in hospital is an essential aspect
of nursing care. Yet wide variations in clinical
practice exist. This article presents a literature
review on oral hygiene (Box 1), focusing on the
care of patients with stroke.
The importance of good oral hygiene is
highlighted in the literature: the persons comfort,
good nutrition, and general wellbeing are promoted
by maintaining clean and well-cared-for teeth and
gums (Nettina 2006). The Essence of Care
benchmark for personal and oral hygiene states
that (Department of Health (DH) 2001):
NURSING STANDARD

Assessment of oral hygiene should be carried

out using a validated tool.
Care should be carried out using best practice.
Assistance should be provided based on
individual need.
Patients should be given information and
education to enable them to meet their oral
hygiene needs.
Whether nurses care for patients in a
high-dependency unit, a general medical ward or in
a nursing home, they have a duty of care to ensure
a good standard of oral hygiene for patients. For
those patients who have had a stroke, oral care
may have added complexities because of spatial
problems, cognitive impairment, poor sitting
balance and upper limb weakness. The increase
in yeasts may increase the incidence of aspiration
pneumonia and oral Candida (Zhu et al 2008).
The National Clinical Guideline for Stroke
(Intercollegiate Stroke Working Party 2008) sets
out specific guidance for the provision of good oral
hygiene 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
(Wrdh et al 2000). Some nurses demonstrate poor
knowledge of oral hygiene practices (Preston et al
2000, White 2000) and, in some circumstances,
may use outdated tools, relying on tradition and
practices passed down from one generation of
nurses to the next (McKenna et al 2000, Pearson
and Hutton 2002). McAuliffe (2007) highlighted
a paucity of oral hygiene education for nursing
students with most of the learning taking place
in the ward environment. There is also evidence
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to suggest that nurses perceive oral hygiene to be
an unpleasant task (Allen Furr et al 2004).
Using a questionnaire approach to investigate
registered nurses approach to oral care for
patients on medical wards, Adams (1996)
concluded that there is a lack of general
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 between
the acute stroke unit at Manchester Royal Infirmary being set up and
the last year of available data before study commencement).

Guideline registers from the National Institute for Health and Clinical
Excellence.

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 the
authors, on request.

BOX 2
Guidance on oral hygiene interventions
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 are
taking 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)

36 may 19 :: vol 24 no 37 :: 2010

knowledge related to oral hygiene among

registered nurses, that untrained healthcare
assistants carry out a substantial amount of oral
hygiene, and that it is deemed a low priority
when staffing levels are low.
Fitzpatrick (2000) reached similar
conclusions in a review of the literature on the
oral hygiene needs of dependent older people
in continuing care settings and the
responsibilities of nursing and healthcare staff.
Nurses knowledge of oral hygiene was
variable and there was an absence of a valid
and reliable assessment tool. Fitzpatrick (2000)
recommended revisiting the educational
preparation of pre and post-registration staff.
In a survey of nurses in Ireland, Costello and
Coyne (2008) reported that some nurses lacked
knowledge of oral care procedures, and had
limited access to assessment tools and to the
correct equipment needed.
Oral hygiene provided on stroke units appears
to mirror that in other care settings. Talbot et al
(2005) conducted a postal survey of ward
managers and senior nurses on stroke units
throughout Scotland. The survey had excellent
response 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 tools
and, in some areas, a lack of toothbrushes and
toothpaste to carry out care.
To provide good oral hygiene, many studies
recommend educating staff, using equipment
that has a sound evidence base and adhering
to validated oral hygiene assessment and care
guidelines (Roberts 2000a, Pearson and Hutton
2002, Allen Furr et al 2004).

Interventions to improve oral hygiene

Brady et al (2006) carried out a review to
compare the effectiveness of staff-led oral
hygiene interventions with the standard care
of oral hygiene for individuals following
stroke. The conclusions of this review illustrate
the gaps in research knowledge and help
to explain the wide variations that exist
in clinical practice.
The review examined randomised controlled
trials that evaluated one or more interventions
designed to improve the oral hygiene of patients
diagnosed with stroke and requiring assistance
with oral hygiene. From more than 8,000
references initially sourced for the review, only
eight were deemed eligible for inclusion. Seven of
these trials were eliminated as they did not provide
information specific to individuals following
stroke. One particular trial that met the inclusion
criteria evaluated an oral hygiene education
training programme delivered to nursing home
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care assistants (Frenkel et al 2001). Of the 412

residents recruited from the 22 nursing homes,
67 had a history of stroke (Frenkel et al 2001).
Considering that there are more than 900,000
people living with stroke in England alone
(Intercollegiate Stroke Working Party 2008), the
need for more research into the oral hygiene needs
of this group of patients is apparent.
Frenkel et al (2001) divided care assistants into
an intervention group that received training and
an oral hygiene care booklet, and a control group
providing standard care, but that received the
training intervention following completion of the
trial. Training sessions focused on the role plaque
plays in oral disease and a practical session on
cleaning techniques for natural teeth and dentures.
A comprehensive tool to assess oral hygiene was
used in the study as part of data collection.
Results suggested that the knowledge and
attitudes of the staff in the intervention group of
carers were, respectively, higher and improved at
both one and six months, compared with the
control group. This in itself should be deemed a
success in light of the literature indicating that
nurses view oral hygiene as a low priority, have
poor knowledge on the subject and perceive oral
hygiene to be an unpleasant task (Preston et al
2000, Wrdh et al 2000, White 2000, Allen Furr
et al 2004).
Residents with dentures who received the
intervention had less plaque on their dentures
at both one and six months. Gingivitis was
less common in the intervention group
at six months compared with residents
receiving only standard care (Frenkel et al
2001). The authors suggested that although
there was an improvement in the intervention
groups oral hygiene, the persistence of high
dental 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 programme
for nursing personnel in special housing facilities
for older people. Knowledge assessment was
undertaken using a questionnaire, and the results
suggested that knowledge was retained three
years after the initial training.
The work by Frenkel et al (2001) and
Paulsson et al (2008) focused on care assistants
working in nursing homes. It could be suggested
that this does not provide insight into the
provision of care in an acute hospital. However,
it is important to recognise that a large amount
of personal and oral hygiene care is carried out
by clinical support workers in hospitals.
Adams (1996) found that non-registered
staff performed a substantial amount of
patients oral hygiene.
NURSING STANDARD

Frenkel et als (2001) study suggests that

the provision of an education programme can
have a positive effect on the knowledge and
attitudes of healthcare staff and a beneficial
effect on patients oral hygiene. However, this
successful outcome was an isolated finding in
Brady et als (2006) review, which concluded
that there is a paucity of high quality evidence
relating to oral healthcare interventions for
individuals after stroke. The authors also
discussed the nature of the specific
rehabilitative role that oral hygiene can have in
the stroke setting and were disappointed that
none 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 general
hospital 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 oral
hygiene given to patients is undertaken
by non-registered staff. Oral hygiene is given
a low priority by registered nurses (Adams 1996,
Fitzpatrick 2000, Wrdh et al 2000).
Evidence and tools There is a lack of empirical
evidence to support which nursing
interventions are effective in maintaining good
oral hygiene (Brady et al 2006). There is
evidence to suggest toothbrushes are the most
effective tool for maintaining good oral
hygiene, but the use of foam sticks remains
prevalent (Pearson and Hutton 2002). There
are a number of examples of oral hygiene
BOX 3
Oral hygiene in the hospital setting: main findings
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 assessment
tools 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 more

effective 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.

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Conclusion

assessment tools being developed, which may

be effective (Roberts 2000a, 2000b and
2000c), but there is no empirical evidence of
their sustained effectiveness.
Education and training Education programmes
that improve nurses knowledge of oral hygiene
care may have positive benefits (Frenkel et al
2001, Paulsson et al 2008). However, education
on assessing oral hygiene needs and planning
and implementing care is limited in continuing
professional development programmes (Talbot
et al 2005, Stout et al 2009). There is also a lack
of formal education on oral hygiene for
undergraduate nursing students, with students
being 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 (Huskinson
and Lloyd 2009, Malkin 2009). The Essence of
Care 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.

This literature review shows the limited evidence

on the effectiveness of interventions in oral hygiene
care is focused on the use of toothbrushes and
education programmes. Further research needs to
be carried out in the acute hospital setting. For
stroke patients in particular, research needs to:
Be undertaken in acute and rehabilitation
stroke settings.
Establish the effectiveness of other
interventions 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 rehabilitation
programme in stroke units is worthy of
further research.
Develop an evidence base for oral care
interventions.
There is limited evidence that education can
change healthcare staffs knowledge and attitude
to improve oral hygiene. The challenge is to
develop an evidence base that defines the nursing
interventions that improve oral hygiene,
particularly for stroke patients NS

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