Impact of Functional Disability on Self-Perceived Oral Problems and Oral Care Behaviors among Stroke Survivors: A Cross-Sectional Study

Background:Stroke is a major cause of functional disability, which is in turn correlated with poor oral health.There is a dearth of studies that have investigated self-reported oral health, a measure of how individuals perceive their oral health and unmet treatment needs, in elders after stroke. Therefore, the purpose of this study was to compare self-perceived oral problems and oral care behaviors between stroke survivors with and without functional disability. Methods:Two-hundred and seven stroke survivors were recruited,comprised of 104 participants without functional disability, and 103 with functional disability, based on the modied Rankin Scale. Interviews were conducted to collect data regarding self-perceived oral problems, oral care behaviors, and dental attendance behaviors. Multivariate logistic regression analysis was performed to compare the data between the two groups. Results: After adjusting for sociodemographic variables, the functional disability group was signicantly less likely to brush their teeth twice a day (odds ratio [OR], 0.388;95%condence interval [CI], 0.200-0.751), and both more likely to have a change in teeth cleaning after stroke (OR, 0.155; 95%CI,0.030-0.804), and to need help when cleaning their teeth (OR, 2.701; 95%CI,1.018-7.163). There were no signicant differences in self-perceived oral problems or dental attendance behaviors between the two groups. Conclusion: Stroke survivors with functional disability had worse oral care behaviors compared with those without functional disability.


Background
Stroke is an acute cerebrovascular disease with a high incidence of disability among elders. [1] The prevalence of stroke among individuals aged > 60 years has been reported as high as 4825/10 million in China in 2013, and, with the rapid aging of the population, this prevalence could increase in the near future. [2] After the recovery phase, nearly half of stroke survivors retain some degree of dysfunction, and approximately 20% are partially or completely in need of care. [3,4] The World Health Organization indicated that oral health plays an important role in quality of life. [5] In 2016, the World Dental Federation reported a new de nition of oral health and emphasized its importance in general health and quality of life. [6] Therefore, oral health needs attention, particularly in stroke survivors.
Previous studies have indicated that functional disability, which can cause inconvenience in oral care, is correlated with poor oral health. [7,8] However, there is limited data on self-reported oral health among stroke survivors with and without functional disability. Self-reported oral health is a widely used measure of oral health in population studies. [9] This simple assessment provides information on how individuals perceive their oral health and unmet treatment needs, [10] and is closely related to clinical examination results. [11] Therefore, the aim of this study was to investigate and compare self-perceived oral problems and oral care behaviors among stroke survivors with and without functional disability.
Statistical analysis Measurement data were tested using the Kolmogorov-Smirnov test. If the distribution was normal, data were expressed as mean (SD); if the distribution was not normal, data were expressed as median (quartile). Count data were expressed as constituent ratio (%). Study variables were divided into two groups according to mean or median. The Chi-square test was used for single-factor analysis.
Interference factors were screened according to single-factor analysis and references, and then a multivariate logistic regression model was used for multivariate analysis. Statistical analyses were performed using SPSS version 22.0 (IBM Corporation) with P < .05 considered statistically signi cant.

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Compared with the non-functional disability group, the functional disability group was more likely to be older (P < .001), without a retirement pension (P = .014), unmarried (P < .001), and with a history of hemorrhagic stroke (P = .001). There were no statistically signi cant differences in sex, education, residence, or time and frequency of stroke between the two groups. (Table 1)   Values are presented as n (%); †based on functional disability group versus non-functional disability group; ‡adjusted for age, sex, education, retirement pension, marriage status, and type of stroke. OR, odds ratio; CI, con dence interval.

Oral Care Behaviors
A low percentage of participants brushed their teeth twice daily, regardless of whether they had (40.8%), or did not have functional disability (58.7%). Furthermore, the large majority of participants (> 90%) maintained the same tooth cleaning habits that they had prior to their stroke. Few participants had a tooth ossing habit, or used uoridated toothpaste. A larger percentage of participants with functional disability reported that they needed assistance with tooth cleaning (17.3%) compared to participants without functional disability (7.8%).
After adjusting for age, sex, education, retirement pension, marriage status, and type of stroke, the functional disability group, who were signi cantly less likely to brush their teeth twice a day (OR, 0.388; 95% CI, 0.200-0.751), also tended to experience a change in tooth cleaning habits after stroke (OR, 0.155; 95% CI, 0.030-0.804), and were more likely to need help when cleaning their teeth (OR, 2.701; 95% CI, 1.018-7.163). There were no signi cant differences in ossing habits, or the use of uoridated toothpaste between the two groups. (Table 3) Values are presented as n (%); †based on functional disability group versus non-functional disability group; ‡adjusted for age, sex, education, retirement pension, marriage status, and type of stroke. OR, odds ratio; CI, con dence interval.

Dental Attendance Behaviors
While most participants had at least one dental visit experience in their lifetime (66.7% and 82.7% of participants with, and without functional disability, respectively), few were regular attendees (1.0% and 8.7% of participants with, and without functional disability, respectively), or had increased their frequency of attendance after stroke (5.8% and 10.6% in participants with, and without functional disability, respectively). Approximately one third (32.7%) of participants without functional disability had visited a dentist within the past year, compared to a quarter (25.2%) of participants with functional disability. Under a fth of all participants had visited a dentist because of tooth or gum pain within the past 6 months, while mouth cleaning within the past year was slightly more prevalent among participants without functional disability (12.5%) compared to participants with functional disability (3.9%).
After adjusting for age, sex, education, retirement pension, marriage status, and type of stroke, the functional disability group was signi cantly less likely to have had at least one dental visit experience in their lifetime (OR, 0.463; 95% CI, 0.200-1.072), and more likely to have visited a dentist because of tooth or gum pain within the past 6 months (OR, 1.128; 95% CI, 0.481-2.646). This group was also less likely to have undergone regular dental examinations (OR, 0.094; 95% CI, 0.009-1.035), visited a dentist within the past year (OR, 0.847; 95% CI, 0.428-1.676), have increased dental attendance after stroke (OR, 0.773; 95% CI, 0.259-2.310), and recent mouth cleaning (OR, 0.518; 95% CI, 0.153-1.753). However, these differences were not signi cant. (Table 4) Values are presented as n (%); †based on functional disability group versus non-functional disability group; ‡adjusted for age, sex, education, retirement pension, marriage status, and type of stroke. OR, odds ratio; CI, con dence interval.

Discussion
To our knowledge, this is the rst report on self-perceived oral problems, oral care behaviors, and dental attendance behaviors among stroke survivors with and without functional disability in China. Our results showed that stroke survivors with functional disability were more likely to have worse oral care behaviors than those without. However, there were no signi cant differences in self-perceived oral problems or dental attendance behaviors between the two groups. This study provides valuable information to better understand the self-perceived oral problems and dental-related behaviors among these vulnerable individuals.
As expected, oral care behaviors declined as functional ability worsened. Stroke survivors with functional disability were less likely to brush their teeth twice a day and more likely to need help when cleaning their teeth. Previous reports have suggested that oral care behaviors are correlated with functional ability and cognitive function. [12][13][14][15][16] Komulainen et al. reported that brushing teeth twice a day was closely related to better instrumental activities of daily living and cognitive function. [13] As is well known, stroke, as a cerebrovascular disease, can cause physical and cognitive disability. [17,18] Our study demonstrated the impact of subsequent functional disability on oral care behaviors.
Our study found no signi cant differences in dental attendance behaviors between stroke survivors with and without functional disability. This might have been attributed to the large proportion of participants who did not undergo regular dental examinations. In other words, the elderly population in our nation does not seem to have a dental visit habit. A previous study in 2011 in America, including 706 stroke survivors, reported that 46% had a dental visit in the previous year. [19] Another study in 2014 in Switzerland showed that 64.2% of elders had a dental visit in the previous year. [20] Our nation should therefore, make a greater effort to promote dental attendance.
To our surprise, our study found no signi cant difference in self-perceived oral problems between stroke survivors with and without functional disability. One reason might be that our participants did not pay much attention to their oral condition. Another reason might be that stroke caused a decline of sensation and cognition, which concealed the self-perceived oral problems. This suggests that a clinical examination should be added in a future study to better understand the oral condition of these individuals. Another limitation is that our study was based on a limited sample size and convenience sampling method. Therefore, studies with a larger sample size and a random sampling method are needed.

Conclusions
Stroke survivors with functional disability had worse oral care behaviors than those without. However, no signi cant differences in self-perceived oral problems or dental attendance behaviors were observed in our study. Therefore, special attention should be paid to improve oral care behaviors of stroke survivors with functional disability.
List Of Abbreviations OR, odds ratio; CI, con dence interval.