|Year : 2015 | Volume
| Issue : 3 | Page : 203-207
Periodontal disease and oral hygiene practices in patients with ischemic stroke
Ritu Jain1, Progya Roy1, Abi M Thomas2, Paramdeep Kaur3, Jeyaraj D Pandian3
1 Department of Public Health Dentistry, Christian Dental College, Ludhiana, Punjab, India
2 Department of Pedodontic and Preventive Dentistry, Christian Dental College, Ludhiana, Punjab, India
3 Department of Neurology, Stroke Unit, Christian Medical College, Ludhiana, Punjab, India
|Date of Web Publication||12-Jun-2015|
Dr. Jeyaraj D Pandian
Department of Neurology, Deputy Director (Research and Development), Christian Medical College and Hospital, Ludhiana - 141 008, Punjab
Source of Support: None, Conflict of Interest: None
Aims: A case-control study was conducted to examine the prevalence of periodontal disease and oral hygiene practices in ischemic stroke patients. Settings and Design: Case-control study. Materials and Methods: This study was conducted from March 2010 to March 2011. Control subjects were either the relatives of stroke patients or selected randomly from the patients reporting to the hospital for treatment. The detailed case history and stroke characteristics were collected. Oral examination was done using the WHO Oral health assessment questionnaire and oral hygiene practices were obtained from the patients. Stroke outcome was assessed using modified Rankin scale (mRS) (good [mRS ≤ 2]; poor [mRS > 2]). Results: One hundred and eight first-ever ischemic stroke patients and 108 age- and gender-matched healthy controls were included. Thirty-six (33.3%) patients showed periodontal damage, only 15 (13.9%) of controls had periodontal involvement (P = 0.001). Periodontal disease was commonly seen in stroke patients than the control subjects (odds ratio 3 [95% confidence interval: 1.6-6.1]; P = 0.0007). Stroke patients (17.4%) were more likely to use a finger or twig to clean their teeth than controls (1.9%) (P < 0.0001). Stroke patients had more number of missing teeth (4.02 ± 5.85) as compared to controls (1.81 ± 3.89) (P = 0.002). Conclusions: Periodontal disease was common in stroke patients as compared to controls. Oral hygiene-related behavior of stroke patients may have a role to play in the complex interplay of factors linking periodontal disease and edentulism to stroke.
Keywords: Attachment loss, oral hygiene practice, periodontitis, risk factor, stroke
|How to cite this article:|
Jain R, Roy P, Thomas AM, Kaur P, Pandian JD. Periodontal disease and oral hygiene practices in patients with ischemic stroke. CHRISMED J Health Res 2015;2:203-7
|How to cite this URL:|
Jain R, Roy P, Thomas AM, Kaur P, Pandian JD. Periodontal disease and oral hygiene practices in patients with ischemic stroke. CHRISMED J Health Res [serial online] 2015 [cited 2019 Oct 19];2:203-7. Available from: http://www.cjhr.org/text.asp?2015/2/3/203/158672
| Introduction|| |
Stroke is a global health problem and a leading cause of adult disability worldwide. In last decade, age-adjusted incidence rate of stroke is increased by 12% in low and middle-income countries (LMICs) and decreased by the same proportion in high-income countries (HICs).  The common modifiable risk factors for stroke include smoking, excess alcohol intake, hypertension, diabetes, obesity, and cardiovascular disease.  Chronic oral infections like periodontitis may be an under-recognized risk factor that may be linked to stroke via several pathways.  Impact of stroke can be reduced by early detection and modifications of risk factors.
Periodontitis is the most common oral infections in humans. Periodontitis was defined as the inflammation of the supporting structure of the teeth characterized by alveolar bone loss and periodontal pocket formation or recession. Globally, periodontitis can affect 90% of the population, and 10-15% of the world population have severe periodontitis. , In a recent multicenter study from India, prevalence of periodontitis in general population of age group 35-44 years ranged from moderate: 15-48%; severe 1-9.7% and in age group 65-74 years moderate periodontitis: 1.7-55.2%; severe 0.6-15.6%.  The prevalence of moderate and severe periodontitis in urban Ludhiana was 43.2% and 22.9%, respectively. 
Gingivitis is the mildest form of the periodontal disease. Gingivitis can develop within days due to the accumulation of dental plaque on the teeth and other nonshedding surfaces in the oral cavity. Periodontal disease may increase the levels of inflammatory mediators in the systemic circulation and initiate atherosclerotic process. ,, Periodontitis may also be linked with stroke through noncausal confounding pathways which may include common risk factors like age, heredity, diabetes mellitus, smoking, socioeconomic status, obesity, health-related behaviors, etc.  Periodontitis results from a complex interaction between the plaque microbes and the inflammatory host response, causing destruction of the supporting tissues of the tooth and ultimately tooth loss.  Several oral bacteria such as Streptococcus sanguis and Porphyromonas gingivalis been implicated in the infectious etiology of atherogenesis.  Furthermore, the types of oral hygiene practices followed by the individuals determine to a large extent their oral and periodontal health. Several studies have found significant associations between stroke and periodontal disease. ,,,,,,,, These studies were mainly conducted in HICs. There is a lack of information from LMICs. Furthermore, little is known about the oral hygiene practice in stroke patients. 
Hence, this study was carried out with the following objectives:
- To find the prevalence of periodontal disease in stroke patients and compare with age and gender matched controls
- To compare the oral hygiene practices followed by stroke patients and controls.
| Materials and Methods|| |
This age- and gender-matched case-control study was conducted in a tertiary hospital in Northwest India from March 2010 to March 2011. All first-ever ischemic stroke patients over 18 years of age admitted in the stroke unit were included. Critically ill patients or patients with Glasgow coma scale < 5 were excluded. 
Control subjects were either the relatives of stroke patients or selected randomly from the patients reporting to hospital for treatment. They were also recruited from Dental camps. These camps are conducted by the hospital at least once in a month in rural villages. Free dental check-up and subsidized treatment are provided in these camps. Controls did not have a stroke and were matched for age and gender.
The baseline demographic details, oral and personal habits, and oral hygiene practices were collected from stroke patients and controls. The baseline demographics collected were age, gender, education, occupation, and religion. Education was classified into lower (illiterates and up to primary level) and upper (secondary school and beyond). Stroke details like risk factors of stroke and severity of stroke (National Institute of Health Stroke Scale)  were collected from patients. Outcome (modified Rankin scale [mRS]: Good [mRS ≤ 2]; poor [mRS > 2]) was documented at 1 months follow-up by telephonic interview. 
Oral health assessment of both cases and controls was done using the WHO oral health assessment form and examination was carried out using a mouth mirror and a WHO probe.  The examination in stroke patients was done within 1-week of hospital admission. For evaluating periodontal destruction, we used two parameters, the community periodontal index (CPI) scores and loss of attachment (LOA).  The CPI included 6 categories: 0: Healthy; 1: Bleeding; 2: Calculus; 3: Pathological pocket 4-5 mm; 4: Pathological pocket 6 mm or more; X: Excluded sextants. For the analysis, it was grouped into two groups as 0-2: Gingivitis; 3-4 periodontitis with pocket ≥ 4 mm.  There are 6 categories in LOA: 0: 0-3 mm; 1: 4-5 mm (cementoenamal junction (CEJ) within black band); 2: 6-8 mm (CEJ between upper limit of black band and 8.5 mm ring); 3: 9-11 mm (CEJ between 8.5 mm and 11.5 mm rings); 4: 12 mm or more (CEJ beyond 11.5 mm ring); X: Excluded sextant.
The number of decayed, missing, and restored teeth was calculated from the dentition status recorded in the WHO oral health assessment performa. A prosthetic need in any of the arches indicates loss of teeth (edentulism) which indirectly may correlate with either severe periodontal damage, teeth missing due to caries or trauma. Prosthetic need consisted five categories: 0: No prosthesis needed; 1: Need for one-unit prosthesis; 2: Need for multi-unit prosthetic; 3: Need for a combination of one and/or multi-unit prostheses; 4: Need for full prosthesis (replacement of all teeth). For the analysis prosthetic need is grouped into two categories: No prosthesis needed and prosthetic needed.
Dental hygiene practice of stroke patients and controls was documented using structured questionnaire. It included information about type of cleaning (toothbrush, finger or twig), method of cleaning (horizontal or vertical), material used to clean the teeth (paste, charcoal etc), frequency of cleaning in a day and time of brushing (before or after meal). Twigs are chew sticks that are made from a tree with antimicrobial properties. Charcoal is black powder prepared by heating wood or other substances in the absence of oxygen. This powder is odorless and tasteless.
A written informed consent was taken from all patients before the questionnaire was administered. The study protocol was approved by the Institutional Research Committee.
Chi-square and Fisher's exact tests were used to study the relationship between categorical variables. Comparisons between continuous variables were done using Student's unpaired t-test. A P < 0.05 was considered significant. Statistical analysis was performed using SPSS version 21.0 (Armonk, NY: IBM Corp 2013).
| Results|| |
This study included 108 ischemic stroke patients, and 108 age- and gender-matched control subjects. There was no significant difference in the demographic details between cases and controls [Table 1]. Thirty-six (33.3%) patients showed periodontal damage, only 15 (13.9%) of controls had periodontal involvement (P = 0.001) [Figure 1]. Periodontal disease was commonly seen in stroke patients than the control subjects (unadjusted odds ratio: 3 [95% confidence interval [CI]: 1.6-6.1]; P = 0.0007).
|Figure 1: Frequency of periodontal disease in stroke patients and controls|
Click here to view
|Table 1: Comparison of demographic details of ischemic stroke patients and controls |
Click here to view
Comparison of dental hygiene practice and intraoral variables between stroke patients and control subjects
Stroke patients 16 (17.4%) were more likely to use finger or twig to clean their teeth as compared to controls 2 (1.9%) (P < 0.0001). The control group was in the habit of brushing more than once a day 29 (26.9%) as compared to patients 7 (7.7%) (P < 0.0001). Stroke patients had more number of missing teeth (4.02 ± 5.85) as compared to controls (1.81 ± 3.89) (P = 0.002).
The average decayed missing filled teeth values in stroke patients (8.7 ± 7) was significantly higher than controls (6.4 ± 5.3) (P = 0.01). More number of stroke patients had CPI index value >3 (pathological pocket ≥4 mm) (P = 0.001). Severe LOA (6-8 mm) was evident in 15 (13.9%) patients and only 5 (4.6%) in control subjects (P = 0.003). Prosthetic need in either upper or the lower arch (stroke patients 75 [69.4%] vs. controls 53 [49.1%]; P = 0.002) was also different between the two groups [Table 2].
|Table 2: Comparison of dental hygiene practice and intraoral variables between ischemic stroke patients and controls |
Click here to view
Differences in risk factors, stroke severity, and outcome in stroke patients with and without periodontal disease
There were no significant differences in risk factors and stroke severity in stroke patients with and without periodontal disease [Table 3].
|Table 3: Stroke characteristics in ischemic stroke patients with and without periodontal disease |
Click here to view
| Discussion|| |
In this study, stroke patients had more periodontal damage and higher CPI values as compared to controls. Severe attachment loss (6-8 mm) was more prevalent in stroke patients. While 69.4% stroke patients showed a prosthetic need in either of the arches, only 49.1% controls showed a need for any prosthesis. Thus, stroke patients were more likely to be suffering from poor oral and periodontal health as compared to controls.
Periodontal infections may act as one of the risk factors which may be linked with stroke via different pathways. Many of the organisms implicated in periodontal infections like porphyromonas gingivalis have been isolated from the atheromatous plaques in stroke patients. These organisms may enter the systemic circulation from the oral cavity during routine activities like tooth brushing. Periodontal infections being inflammatory in nature may also increase the levels of pro-inflammatory mediators circulating in the blood thus initiating atherogenic processes. Apart from these, periodontitis may be linked to stroke through noncausal pathways by the involvement of common risk factors like age, heredity, obesity, diabetes mellitus, smoking, etc. , Periodontal status of a patient is also determined by the type of oral hygiene practices followed by them.
In this report, poor dental hygiene practices were common in stroke patients, which is similar to other studies linking poor dental status and periodontal disease. ,,, According to Wu et al. 2000, gingivitis and periodontitis were significant risk factors for both incident and fatal stroke.  A recent hospital-based case-control study reported from India, stroke patients had higher mean values for various gingival and periodontal parameters as compared to controls.  Probing depth of >4.5 mm was found to be highly significant for stroke risk with an odds ratio of 8.5. 
The reason for edentulism is difficult to determine and may be related to caries, periodontal disease, poor nutrition or trauma. This may result in a residual confounding effect, and thus we cannot establish a direct causal relationship between prosthetic needs and stroke. Our results are similar to Elter et al. They found a higher frequency of attachment loss and edentulism in stroke patients but could not establish a cause and effect relationship.  Frequency of tooth cleaning indicates oral hygiene-related behavior, thus patients with poor oral hygiene practices were significantly more likely to develop stroke and as these patients may also be more likely to develop periodontal disease this further strengthens the relationship between periodontal destruction and stroke.
One of the limitations of this study was the exclusion of severity of gingival inflammation in our oral parameters. In another study, gingivitis was independently associated with cerebral ischemia.  There is no universal definition or cut-off for periodontal disease, and the measures vary in different investigations. The effect of past periodontal destruction is quantified by attachment loss, but that variable is also affected by the loss of teeth especially those lost because of severe periodontitis. Thus, quantification of periodontal disease is not easy.
| Conclusion|| |
Periodontal disease was common in stroke patients as compared to controls. Oral hygiene-related behavior of stroke patients may have a role to play in the complex interplay of factors linking periodontal disease and edentulism to stroke. In future, studies with larger sample size are necessary to verify and quantify the role of gingival and periodontal infection in the pathogenesis of stroke.
| Acknowledgment|| |
The authors would like to thank Dr. Simran Singh Gill, Dr. Avneet Kaur and the interns posted in the Department of Public Health Dentistry during the period of the study for their help in collecting the data.
| References|| |
Feigin VL, Forouzanfar MH, Krishnamurthi R, Mensah GA, Connor M, Bennett DA, et al.
Global and regional burden of stroke during 1990-2010: Findings from the Global Burden of Disease Study 2010. Lancet 2014;383:245-54.
Pandian JD, Srikanth V, Read SJ, Thrift AG. Poverty and stroke in India: A time to act. Stroke 2007;38:3063-9.
Elter JR, Offenbacher S, Toole JF, Beck JD. Relationship of periodontal disease and edentulism to stroke/TIA. J Dent Res 2003;82:998-1001.
Pihlstrom BL, Michalowicz BS, Johnson NW. Periodontal diseases. Lancet 2005;366:1809-20.
Petersen PE, Ogawa H. Strengthening the prevention of periodontal disease: The WHO approach. J Periodontol 2005;76:2187-93.
Shah N, Pandey RM, Duggal R, Mathur VP, Rajan K. Oral Health in India: A report of the multi centric study, Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India and World Health Organisation Collaborative Program; December, 2007.
Singh GP, Bindra J, Soni RK, Sood M. Prevalence of periodontal diseases in urban and rural areas of Ludhiana, Punjab. Indian J Community Med 2005;30:128-9.
Meurman JH, Sanz M, Janket SJ. Oral health, atherosclerosis, and cardiovascular disease. Crit Rev Oral Biol Med 2004;15:403-13.
Chun YH, Chun KR, Olguin D, Wang HL. Biological foundation for periodontitis as a potential risk factor for atherosclerosis. J Periodontal Res 2005;40:87-95.
Joshipura KJ, Ritchie CS. Strength of Evidence Relating Periodontal Disease and Cardiovascular Disease. Inside Dentistry. 2006; 2:1-9. [International Consensus Statement].
Kinane DF. Causation and pathogenesis of periodontal disease. Periodontol 2000 2001;25:8-20.
Noack B, Genco RJ, Trevisan M, Grossi S, Zambon JJ, De Nardin E. Periodontal infections contribute to elevated systemic C-reactive protein level. J Periodontol 2001;72:1221-7.
Haraszthy VI, Zambon JJ, Trevisan M, Zeid M, Genco RJ. Identification of periodontal pathogens in atheromatous plaques. J Periodontol 2000;71:1554-60.
Lafon A, Tala S, Ahossi V, Perrin D, Giroud M, Béjot Y. Association between periodontal disease and non-fatal ischemic stroke: A case-control study. Acta Odontol Scand 2014;72:687-93.
Hashemipour MA, Afshar AJ, Borna R, Seddighi B, Motamedi A. Gingivitis and periodontitis as a risk factor for stroke: A case-control study in the Iranian population. Dent Res J (Isfahan) 2013;10:613-9.
Sfyroeras GS, Roussas N, Saleptsis VG, Argyriou C, Giannoukas AD. Association between periodontal disease and stroke. J Vasc Surg 2012;55:1178-84.
Sim SJ, Kim HD, Moon JY, Zavras AI, Zdanowicz J, Jang SJ, et al.
Periodontitis and the risk for non-fatal stroke in Korean adults. J Periodontol 2008;79:1652-8.
Dörfer CE, Becher H, Ziegler CM, Kaiser C, Lutz R, Jörss D, et al.
The association of gingivitis and periodontitis with ischemic stroke. J Clin Periodontol 2004;31:396-401.
Grau AJ, Becher H, Ziegler CM, Lichy C, Buggle F, Kaiser C, et al
. Periodontal disease as a risk factor for ischemic stroke. Stroke 2004;35:496-501.
Joshipura KJ, Hung HC, Rimm EB, Willett WC, Ascherio A. Periodontal disease, tooth loss, and incidence of ischemic stroke. Stroke 2003;34:47-52.
Beck J, Garcia R, Heiss G, Vokonas PS, Offenbacher S. Periodontal disease and cardiovascular disease. J Periodontol 1996;67:1123-37.
Wu T, Trevisan M, Genco RJ, Dorn JP, Falkner KL, Sempos CT. Periodontal disease and risk of cerebrovascular disease: The first national health and nutrition examination survey and its follow-up study. Arch Intern Med 2000;160:2749-55.
Kim EK, Jang SH, Choi YH, Lee KS, Kim YJ, Kim SH, et al.
Effect of an oral hygienic care program for stroke patients in the intensive care unit. Yonsei Med J 2014;55:240-6.
Teasdale G, Jennett B. Assessment and prognosis of coma after head injury. Acta Neurochir (Wien) 1976;34:45-55.
Brott T, Adams HP Jr, Olinger CP, Marler JR, Barsan WG, Biller J, et al.
Measurements of acute cerebral infarction: A clinical examination scale. Stroke 1989;20:864-70.
Rankin J. Cerebral vascular accidents in patients over the age of 60. III. Diagnosis and treatment. Scott Med J 1957;2:254-68.
WHO. Oral Health Survey-Basic Methods. 4 th
ed. Geneva: AITBS Publishers and Distributers; 1997.
Pradeep AR, Hadge P, Arjun Raju P, Shetty SR, Shareef K, Guruprasad CN. Periodontitis as a risk factor for cerebrovascular accident: A case-control study in the Indian population. J Periodontal Res 2010;45:223-8.
[Table 1], [Table 2], [Table 3]
|This article has been cited by|
||Oral Health Interventions Using Chlorhexidine—Effects on the Prevalence of Oral Opportunistic Pathogens in Stroke Survivors: A Randomized Clinical Trial
| ||Normaliza Ab Malik,Fathilah Abdul Razak,Saćari Mohamad Yatim,Otto Lok Tao Lam,Lijian Jin,Leonard S.W. Li,Colman McGrath |
| ||Journal of Evidence Based Dental Practice. 2017; |
|[Pubmed] | [DOI]|
||Integrated oral health care for stroke patients - a scoping review
| ||Shilpi Ajwani,Sumedh Jayanti,Nadia Burkolter,Craig Anderson,Sameer Bhole,Rhonda Itaoui,Ajesh George |
| ||Journal of Clinical Nursing. 2016; |
|[Pubmed] | [DOI]|