Design and objective
This cross-sectional study was carried out in the neurology departments of two tertiary public hospitals and one tertiary private hospital between Nov 2021 and Feb 2022 in the urban area of Guangzhou, Guangdong Province, China. A convenience sampling method was used. The aims of this study were (1) to determine the current status of participants' oral health knowledge, attitudes, and behaviours and (2) determine the factors influencing the participants’ OHRQoL.
The study population included stroke inpatients in the Department of Neurology, Nanfang Hospital of Southern Medical University, Baiyun Branch of Nanfang Hospital of Southern Medical University, and Guangdong 999 Brain Hospital. A total of 281 hospitalised stroke patients (219 males and 62 females) participated in this study. The inclusion criteria for this study were as follows: (1) patients who met the diagnostic criteria of “Diagnostic Points for Various Major Cerebrovascular Diseases in China 2019” and were diagnosed with stroke after computed tomography (CT) or magnetic resonance imaging (MRI) examination; (2) age ≥ 18 years; (3) inpatients who were conscious and had stable vital signs; (4) patients with the ability to read, communicate and understand; and (5) patients and caregivers who volunteered to participate in this study. The exclusion criteria were (1) patients with oral tumours or acute oral infections, difficulty in opening the mouth, or other oral trauma; (2) patients with other central nervous system diseases, malignant tumours, and other serious comorbidities or obvious complications; and (3) patients with tracheal intubation, tracheotomy, indwelling nasogastric tube, or nasogastric tube. The survey was conducted in the medical staff examination and assessment section by a nurse who was trained in neurological and dental expertise and skills and was proficient in the application of the swallowing function assessment, nutritional assessment and oral assessment tests.
The purpose of this study was explained to the patient or caregiver by the investigator before the start of the study. All patients participated in the study voluntarily and had the right to withdraw from this study at any time and without interference with their treatment. Verbal and informed consent was obtained by the investigator from the patient or their caregiver before the relevant tests and assessments. Informed consent was signed by all participants in this study, and if the participant was a dependent, signed informed consent was obtained from their caregiver. The caregiver was the legal guardian, usually the patient’s spouse or adult child . Participants were supervised while completing the questionnaire, which was returned immediately after completion. The Medical Ethics Committee of the Southern Hospital of Southern Medical University approved this study (NFEC-2022-015).
The demographic information of the participants included 18 items, including sex, age, education level, occupation, monthly household income per capita, permanent address of the family, lifestyle and dietary habits, marital status, residence status, primary family caregiver after admission, number of strokes, type of stroke, time of the first stroke, chronic diseases, dentures, number of teeth, number of missing teeth and existing poor oral status. This questionnaire was based on select questions from the World Health Organization (WHO) Oral Health Questionnaire for Adults 5th edition  and the Fourth National Oral Health Survey Questionnaire (Adult Version)  in China. It was a three-part questionnaire to investigate the oral health KAP of patients hospitalised with stroke. In this study, the Cronbach′s α coefficient for the knowledge and attitudes section of this questionnaire was 0.81.
The first section was an oral health knowledge survey consisting of 8 questions answered correctly, incorrectly or “do not know”. The questions were as follows: (1) it is normal for gums to bleed when brushing; (2) bacteria can cause inflammation of the gums; (3) brushing is not useful in preventing bleeding gums; (4) bacteria can cause tooth decay; (5) eating sugar can cause tooth decay; (6) fluoride is not useful in protecting teeth; (7) brushing protects teeth; and 8) oral disease may affect the health of the entire body’. Finally, patients were asked about how they learned about oral health. The overall rate of oral health knowledge was equal to the total number of knowledge questions answered correctly/(number of knowledge items per questionnaire x the number of participants with valid answers) × 100%.
In the second section, attitudes towards oral health were ascertained through five questions. The responses were agree, disagree and do not know. The questions were as follows: (1) Oral health is important to one’s life; (2) regular oral check-ups are essential; (3) good or bad teeth are innate and have little to do with one’s own protection; (4) preventing dental diseases depends on oneself first and foremost; and (5) maintaining oral health promotes one’s own health. The total rate of positive attitudes towards oral health was equal to the total number of positive attitude questions/(the number of attitude items in each questionnaire x the number of participants with valid responses × 100%).
In the third section, oral health practices were examined through 12 questions: (1) frequency of brushing or rinsing (3 times a day, 2 times a day, once a day, 3–6 times a week, 1–2 times a week); (2) oral cleaning methods (toothbrush, electric toothbrush, floss, toothpick, mouthwash); (3) toothpaste used (fluoride, no fluoride, none or unknown); (4) mouthwash (tap water, warm water, physiological saline, chlorhexidine, other); (5) frequency of toothbrush replacement (3 months, 3–6 months, 6–12 months, 1–2 years, replace when broken); (6) primary oral cleaner after hospitalization (self, family, nurse, caregiver, none); (7) denture cleaning method (Questions 7–8 were skipped if no dentures. Boiling water soak, warm water soak, cold water soak, toothbrush soak, disinfectant soak, other); (8) frequency of denture cleaning (3 times a day, 2 times a day, once a day, 3–6 times a week, 1–2 times a week); (9) time since the last dentist visit (within 6 months, 6–12 months, 1–2 years, 2–5 years, more than 5 years, have not been or do not remember); (10) reason for the last dentist visit (have not been or do not remember, seeking advice or recommendations, tooth, gum or mouth pain and discomfort, treatment or follow-up, routine check-up or treatment, other); (11) reasons for not having visited a dentist in the past year (no dental problems, dental disease not serious, no time, financial difficulties, fear of epidemic transmission, difficulty in registering or no dentist nearby, fear of painful dental visits, other); and (12) frequency of dental cleaning in the clinic or hospital (every 3 months, every 6 months, every year, every 2 years, every 3 years or more, never).
Barthel index (BI)
The Barthel Index (BI) was first described in the 1950s, and it is an interview-based approach to assess participants’ activities of daily living (ADL) . It consists of 10 items including feeding, bathing, grooming, dressing, bladder control, bowel control, toilet use, moving, transferring, and going up and down stairs. Scores range from 0 (fully independent) to 100 (fully independent) depending on the patient’s independence in each task . Studies have shown that the BI has good reliability and is suitable for the assessment of poststroke patients .
Nutritional risk screening (NRS 2002)
This screening tool developed by the Danish Society for Parenteral and Enteral Nutrition scores patients on two separate components, (1) undernutrition and (2) disease severity, depending on whether they are absent, mild, moderate, or severe, with a total score of 0–6. Patients achieving a total score of ≥ 3 are classified as having nutritional risk .
Water-swallowing test (WST)
The Kubota drinking water test, which was proposed by the Japanese scholar Toshio Kubota, is graded and simple to perform  and is a sensitive screening tool that is widely used in neurology departments in China. The WST is usually performed with 90 ml of clear liquid, but the risk of aspiration, asphyxia, and other complications in patients in the acute phase of stroke cannot be ignored when large amounts of water are used in screening. Therefore, a modified version of the WST using a smaller amount of water (30 ml) was used in this study. The patient was asked to drink 30 ml of warm water from a cup while sitting in an upright position to observe the time required to drink and choking. Grade I meant that the patient swallowed the water smoothly in one sitting within 5 s, Grade II meant that the patient swallowed the water in more than 2 parts without choking, Grade III meant that the patient swallowed the water in one sitting with choking, Grade IV meant that the patient swallowed the water in more than 2 parts with choking, and Grade V meant that the patient choked frequently and could not swallow all the water. A grade I patient was considered normal; a grade I patient who swallowed the water in more than 5 s,a grade II patient who was suspected to have a swallowing disorder, and grade III patients and above were considered to have dysphagia.
Self-rated oral health and general health
The self-rating of oral and physical health was assessed. A 5-point scale was used for assessment (1 = ”very poor”, 2 = ”poor”, 3 = ”fair”, 4 = ”good”, 5 = ”very good”) .
Oral health impact profile-14 (OHIP-14)
The impact of OHRQoL was measured using the Chinese continental version of the Oral Health Impact Profile-14 (OHIP-14), validated by domestic scholars, with a Cronbach′s alpha coefficient of 0.93 in the Chinese version. Four common factors were extracted from the 14 entries: diminished independence, psychological discomfort, discomfort in physical functioning, and pain and discomfort of the mouth, with a cumulative contribution of 72.6% . The questionnaire included 14 problems related to the experience: articulation difficulties, degradation of taste, pain, discomfort during eating, self-consciousness, emotional tension, dissatisfaction with eating, interruption of eating, difficulty relaxing, embarrassment, irritability, inability to complete daily tasks, reduced satisfaction with life, and complete inability to work. The frequency of occurrence was assessed on a five-point Likert scale: 0 = never, 1 = seldom, 2 = sometimes, 3 = frequently, and 4 = very often. All values were summed to calculate a total OHIP-14 score, which can vary between 0 and 56; the higher the OHIP-14 score, the worse the OHRQoL. The options “very often” or “often” were considered to have a negative impact on the patient. In the present study, the Cronbach′s α coefficient for the OHIP-14 was 0.87.
Data were analysed using IBM® SPSS® Statistics 26.0. Means ± standard deviations or frequencies and percentages were used to describe participants’ demographic information and oral health KAP and self-rated general and oral health status. The OHIP-14 score data were nonnormally distributed, and the Mann‒Whitney U test and Kruskal‒Wallis H test were uesed to assess differences in sample characteristics. Spearman’s correlation was used to assess the correlation between the variables and OHRQoL. All significant variables were entered into a multiple linear regression with OHRQoL as the dependent variable, and a stepwise regression method was performed to control for the effects of possible confounding factors. Two-tailed tests were used in all analyses, and the significance level was set at P < 0.05.