Brushing Teeth and Oral Hygiene After a Stroke (How to Apply Toothpaste) – Occupational Therapy

This guide provides some ideas and insights into occupational therapy intervention for oral care after a stroke in the hospital (acute care, acute rehab).

Barriers

• Pain: generalized, involved limbs
• Dizziness: from vision, medications
• Poor balance
• Motivation, Depression
• Vision and perception: inattention, neglect, field cut
• Proprioception
• Hemiparesis
• Tone: hypo- or hypertonicity
• Sensation: impaired
• Attention: short
• Memory: impaired memory compared to baseline
• Problem-solving: lacking or poor
• Sequencing
• Apraxia
• Confusion
• Communication: aphasia

Supplies and requirements

For this activity, you will need:

• Out of bed orders
• Dysphagia clearance (fluids – water when rinsing or when water flossing)
• Toothbrush (regular or electric — charged and ready)
• Toothpaste
• Mouthwash (optional)
• Floss (regular, picks, or Waterpik)
• Towels (cloth or paper)
• Mirror for visual feedback (optional)
• Wheelchair or chair for safety

Assistance Levels

1. Dependent (poorer prognosis)
2. 2 person
3. Max
4. Mod (better prognosis)
5. Min (good prognosis)
6. CGA / SBA
7. Supervised
8. Independent: big picture — discharge?

Cueing

Types of cueing you can use include:

• Visual
• Verbal/auditory
• Physical (e.g., hand over hand)
• Proprioceptive
• Combination of the above

Consider the frequency and interval of when you provide these cues. Sparsed cues may encourage problem-solving. However, too frequent of cues may inhibit learning, but too sparse may increase risks for falls and injury.

Locations and Positions

Patients often find performing oral care easiest in bed with the head of bed up. Care must be taken when initiating oral care for patients with dysphagia who are at risk for aspirating fluids. Patients with severe cognitive impairment may benefit from increased supervision and hand-over-hand for oral care with set-up for supplies.

Patients then progress to oral care at the edge of bed while ‘dangling’. The bed height can be raised or lowered to grade the task. Depending on sitting balance, patients may require additional support or helpers. If patients have pusher syndrome, sitting balance will be more impaired and oral care more difficult due to poor midline orientation. Mirrors as visual feedback (biofeedback) may help. Computer-based interventions using video gamification as an activity is shown to be even more effective for pusher syndrome after stroke (n=12).^[1]Yang, Y. R., Chen, Y. H., Chang, H. C., Chan, R. C., Wei, S. H., & Wang, R. Y. (2015). Effects of interactive visual feedback training on post-stroke pusher syndrome: a pilot randomized … Reference List

Sitting while performing oral care can prove to be difficult as many body systems are involved: attention, sitting balance, proprioception, core strength, cognition, and loss of prior function based on learned habits for oral care.

As sitting balance improves with OT and PT, patients can begin rehabilitation of standing oral care after a stroke. While this may be intimidating for the patient, reassure them that there are multiple safeguards to prevent a fall. The OT, environment supports such a stable sink and mirror, a wheelchair behind them, and good lighting. Even static standing can be challenging for the patient due to hemiparesis of the involved lower extremity. This is a good opportunity for the patient to use the impaired upper limb for weight-bearing and the other for brushing teeth.

There is much debate about use vs. learned non-use and which limb to use and when to begin therapy on them. This depends largely on the client, their goals, strengths, and natural habits. Research may support using the involved limb, e.g., CIMT protocol or using the uninvolved limb. If there is significant involvement of the upper extremity, the patient may have not much choice but to use the uninvolved limb to perform the activity.

When the patient masters static standing using support they may progress to static unsupported standing. Encourage dynamic standing balance as well such as reaching for objects, e.g., toothbrush, toothpaste, cups, and towels.

The OT often stands on the involved side in case of a fall. I like to have a wheelchair behind the patient to (1) provide additional safety in case of fatigue and (2) improve patient confidence and make them feel safe. Or you can opt for a simple chair with armrests behind them if there is no wheelchair nearby. Keep in mind that if the patient is not ambulatory, you will likely need to find a wheelchair to transfer into.

Pro Tip: perform dressing after oral care as patients may get a little messy and end up with toothpaste on their hospital gown and clothes and defeat the purpose of wearing clean clothes.

Transfers

See the general guide on transfers

Oral Care Steps and Sequencing

Flossing

Regular floss can be difficult to use in general. Personally, I use floss picks as I find it difficult to reach some teeth with enough force to remove debris and food (especially the back). Patients who wish to floss may benefit from floss picks such as the plastic disposable ones. A Waterpik is another good option and fairly manageable for a patient after a stroke.

Using involved or uninvolved hand:

1. Turn on the water.
2. Fill a cup with some water.
3. Pour water into Waterpik water container.
4. Put the empty cup down.
5. Grab the Waterpik nozzle and place into mouth.
6. Bite down softly or use lips to hold in mouth without holding. (This prevents water from splashing everywhere when the Waterpik is turned on.)
7. Use the same hand to turn on the Waterpik switch.
8. Some Waterpiks have an additional switch on the nozzle – turn this on when ready.
9. Work your way through all the teeth, gums, and gaps.
10. Take resting breaks as necessary by biting down on the nozzle and immediately turning off the Waterpik.
11. Repeat prior steps to refill additional water if needed.

Applying Toothpaste One-handed

1. Place toothbrush down with bristles facing up.
2. Uncap toothpaste either by twisting or popping it off.
3. Squeeze toothpaste onto the toothbursh.
4. Cap the toothpaste.
5. Brush teeth with the same hand using the toothbrush.

Applying Toothpaste Two-handed with Hemiparesis

Many patients struggle with using both hands to apply toothpaste. They often attempt to hold the toothbrush with the unaffected hand and squeeze the toothpaste with the affected hand. This can be quite difficult due to hemiparesis. The opposite is easier:

1. Pick up the toothbrush with the uninvolved hand.
2. Transfer the toothbrush to the involved hand. Even with hemiparesis, all that is needed is to hold the toothbrush steady enough to have toothpaste applied and not drop into the sink or ground.
3. Use the involved hand to uncap the toothpaste or pop-top and then squeeze toothpaste onto the toothbrush in the involved hand.
4. Place toothpaste down.
5. Transfer the toothbrush back to the uninvolved hand.

An alternate way using the same steps is instead of holding the toothbrush in the air at step 2 is to have the involved hand resting the toothbrush onto the inside sink edge, ie, weight-bearing. (The toothbrush is sandwiched between the sink and involved hand with the bristles facing upwards.) This promotes sensory feedback and the use of the involved hand. Toothpaste is applied in the same manner using the uninvolved hand.

Another even easier ‘lazy’ way I have seen patients incorporate toothpaste is to simply suck toothpaste into the mouth straight from the tube of toothpaste itself. This works really well with smaller travel-sized toothpaste as it is lighter and contains less volume inside to make sucking out of it easier.

Wrap-up

Oral care is important for all patients as it maintains oral hygiene, prevents diseases, and promotes a structured routine. No matter the location and severity of the brain lesion, OTs play a role in promoting and re-educating patients on how to brush their teeth and floss. While steps and ideas are presented in this guide, there is technically no wrong way of performing oral care as long as the patient is safe and it does not inhibit recovery.