Tooth-Brushing Ability After Left Stroke

PURPOSE: The purpose of this pilot study was to examine tooth-brushing ability after left stroke using the ipsilateral, nondominant, left limb.

RATIONALE: For right-handed people, left stroke often results in profound motor impairment of the right, dominant hand. In this case, there is increased reliance on the left, nondominant, ipsilateral hand, which can be affected after stroke. This results in difficulty performing daily tasks requiring skilled use of the hand, such as tooth brushing.

Long-standing plaque on tooth surfaces makes teeth more vulnerable to decay, periodontal disease, and ultimately tooth loss. Studies have also shown that presence of high bacterial load in the mouth increases risk of developing pneumonia and infective endocarditis and potentially causes systemic infections. Tooth brushing is the primary method to remove accumulated dental plaque, and, to date few studies have explored tooth brushing after stroke. This is particularly concerning because tooth brushing depends highly on the user’s ability to manipulate the toothbrush.

Clarifying tooth-brushing ability and how ipsilateral deficits, including apraxia, contribute will be important to future patient care and development of specific oral hygiene instruction for people after stroke.

DESIGN: Pilot, observational, cross-sectional study to establish baseline data describing tooth-brushing ability after left stroke using the ipsilateral, nondominant left limb.

PARTICIPANTS: We recruited only right-handed adults after unilateral, first-time left stroke with at least two natural teeth in each quadrant of the mouth. We excluded people with history of bilateral stroke, other neurological diseases that could cause motor disability, and severe aphasia.

METHOD: At Visit 1, we gauged ipsilateral left arm–hand function by assessing tapping speed and administering sensorimotor tests. We also used a validated measure of apraxia. Participants were instructed to refrain from brushing teeth 12 hr before Visit 2.

At Visit 2, participants were seated, and a disclosing agent that reacts with plaque was applied to all visible tooth surfaces. After we recorded plaque index score using a standardized method, participants were asked to brush their teeth using their nondominant, left hand and a manual toothbrush without toothpaste. Instructions were limited to brushing in each quadrant for 30 s in a standard sequence (upper left, lower left, upper right, lower right). After brushing, we evaluated postbrushing plaque index score. Visit 3 was exactly as Visit 2, except participants brushed with a power toothbrush.

ANALYSIS: Paired t tests compared tooth-brushing efficiency (post plaque score – pre plaque score) and independent t tests evaluating manual versus power tooth-brushing ability.

RESULTS: Seven participants (mean age = 61.34 yr, standard deviation = 11.88) participated. Paired t tests revealed significant differences pre- and postbrushing for manual (t = 5.521, p = .001) and for power tooth brushing (t = 5.731, p = .001). An independent t test revealed significant differences between manual and power tooth brushing (t = –2.74, p = .018).

DISCUSSION: This small study suggests that people brush better using a manual toothbrush versus a power toothbrush. All our study participants reported using manual toothbrushes, and perhaps familiarity and routine may be an important factor of tooth-brushing ability using the left, nondominant hand.

IMPACT STATEMENT: It is perhaps insufficient to merely suggest people after stroke use a power toothbrush. Rehabilitation of the ipsilateral hand warrants additional consideration, particularly for specific tasks requiring skilled use of the hands, such as tooth brushing, which has an impact on oral and overall health.