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DH3 Special Needs/Disabilities Research Paper

Heather Wilhelmi

Cerebrovascular Accident (CVA), Stroke

June 2015

A Cerebrovascular Accident (CVA) is also known as a stroke. A stroke


happens when there is a sudden loss of blood flow to the brain which lowers
oxygen levels and results in brain cell damage and/or death. There are 2
main types of strokes. An ischemic stroke is when a blood clot or debris like
plaque block a blood vessel. A hemorrhagic stroke happens when a blood
vessel ruptures leaking blood into the brain tissues.
There are also mini strokes called transient ischemic strokes (TIA).
These are known as warning strokes that normally do not leave permanent
damage to the brain, but does increase a persons risk for recurrent more
damaging strokes. It is caused by a temporary blood clot and causes flu like
symptoms (Hebl, L., 2015, 102).
CVA is the 3rd leading cause of death in the U.S. causing 800,000 per
year. It is estimated that there is 1 stroke every 40 seconds. One in three
strokes result in permanent damage (Hebl, L., 2015, 102). According to the
American Stroke Association, 80% of strokes are preventable (Dennis, L. &
Sen, S. 2015, Vol. 13 No. 4).
Often strokes are not progressive. Sometimes a stroke can deteriorate
a persons condition over a short period of time. In these cases, usually due
to a hemorrhage, the stroke is considered progressive and can last a week or
more. A person is at a higher risk for reoccurring strokes following the first
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one. This makes it a life ling condition and predisposing factors must be
eliminated or controlled to lower the risks.
The history of stroke began 2,400 years ago when the Hippocrates first
recognized it. The Greeks named it apoplexy. In the mid-1600s Jacob Wepfer
dissected corpses in Italy and discovered that the blood supply in the brains
of people that died from apoplexy was disrupted. The arteries were blocked
or there had been a massive bleed into the brain. Then it was not until 1928
when there were more advances made by medical science research to
identify the causes, symptoms, and treatments. The name apoplexy was
changed to Cerebral Vascular Accident, also known as a stroke (Healthline
Editorial Team 2011, February 1).
There are many predisposing risk factors. Hypertension, blood
pressure greater than 140/90, is the greatest risk factor. Smoking can
damage blood vessels raising blood pressure (NIH 2014, March 26). Diabetes
impairs the circulation by not adequately moving blood sugar. Diabetes also
impairs the immune system making a person more susceptible to infections
and slow healing (Wilkins, E. 2014, p.1042-1057). Coronary heart disease,
cardiomyopathy, heart failure, atrial fibrillation and atherosclerosis all
increase risks of clot developments. Aneurysms, a bulge in a vein, and
arteriovenous malformations, faulty arteries and veins, can burst leading to a
stroke. Aging puts a person at greater risk. Men are more likely than women
to have a stroke, yet women are more likely to die when suffering from a
stroke. African American, Alaska native, and American Indians are more
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likely to suffer a stroke over other ethnicities. Family history is also a


contributing factor (NIH 2014, March 26). Other contributors include high
cholesterol, oral contraceptives, drug use, and obesity due to poor nutrition
or inactivity (Hebl, L., 2015, 102). The highest number of strokes happen in
the Southeast region of the U.S., also called the stroke belt. This includes
AR, LA, MS, TN, AL, GA, SC, NC (Dennis, L. & Sen, S. 2015, Vol. 13 No. 4).
Emerging evidence shows a relation between stroke and oral health.
The better a persons oral health the lower the risk of stroke (Dennis, L. &
Sen, S. 2015, Vol. 13 No. 4).
Periodontal diseases may cause local and systemic inflammation, and
growing evidence suggests that periodontal infection may be linked to an
increase in atherosclerosis-induced conditions such as stroke (Dennis, L. &
Sen, S. 2015, Vol. 13 No. 4). According to a flyer I received at a RDH seminar
many researchers believe that bacteria from gum infections could be one of
the infections involved with injury to the artery wall, atherosclerosis.
Bacteria causes an inflammatory response where they can enter the blood
stream through the sulcus and travel to other sites in the body. The arteries
traveled become less elastic and smaller resulting in clogging of the artery.
Signs and symptoms of a stroke can vary per person and incidence.
These can include facial drooping, arm weakness or drifting, slurring,
confusion, headache, problems breathing and/or loss of balance. It is critical
to seek treatment immediately to help lessen the length and severity of a

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stroke. When a stroke is suspected the patient will be given t-PA through an
IV, which is a medicine that quickly dissolves a blood clot to restore blood
flow. This increases a persons chances of a full recovery (Dennis, L. & Sen,
S. 2015, Vol. 13 No. 4).
A doctor can complete multiple tests to determine if a stroke has
occurred. The 2 most common tests are a Brain CT Scan or a MRI. If brain
cells are damaged or die due to a stroke the body is affected in the area that
the brain cells controlled (NIH 2014, March 26). A stroke on the right side of
the brain affects the persons verbal communication and they are anxious,
cautious, and disorganized. A stroke on the left side of the brain affects
physical abilities and coordination along with being overconfident (Hebl, L.,
2015, 102). Strokes can affect the body in many various ways making it
critical to review all patient history information to best prepare for an
appointment. High level affects include language, speech, memory,
muscles, nerves, bladder, bowel control, swallowing, mastication, judgement,
and behaviors (NIH 2014, March 26).
The medications taken are dependent on the cause(s) of the stroke.
The goal is to treat the cause and lower the risk for a recurrent stroke. These
medicines include antihypertensive to help control high blood pressure,
statins to lower cholesterol, glycemic to control diabetes, anticoagulants or
anti-platelets to lessen clotting risks, and nicotine replacement medicines to
assist in stopping smoking (Dennis, L. & Sen, S. 2015, Vol. 13 No. 4).

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While the stroke specifically will not affect the oral cavity, unless there
was trauma such as a fall at the time. Paralysis, motor movements, and
mental disabilities due to brain cell damage from the stroke can inhibit the
patient from having good oral hygiene. The medications used to control the
underlying issue(s) can have a great affect. There are many statins, antihypertensive, and diabetic medicines that will vary per patient based on
other conditions they may have. The effects include muscle weakness of the
jaw, xerostomia which increases the risk of caries and periodontal disease,
taste aversion affecting diet, and hyperplasia of the gingiva. Bupropion
which can be used for a smoking cessation could cause xerostomia and
thrombocytopenia. Warfarin and aspirin can both increase bleeding. The INR
must be monitored. Warfarin can also contribute to mouth ulcers and taste
perversion (Wynn, R., Meiller, T., & Crossley, H. 2014).
Communication and education with the patient and caregiver before,
during, and after the appointment is of the upmost importance. Verify the
health conditions, if they are controlled, and what medications are taken.
This will set the base for the appointment. Remember that there is a large
variety of causes and outcomes from having a stroke.
A person must not be treated for 6 months following a stroke and must
have a release from their physician stating they can be treated. Varying the
dental treatment should be based on individual needs of the patient and
their specific circumstances. The patients status can range from selfsufficient to needing assistance from a care giver. In general, it is normally
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best to have short appointments with small increments of scaling (Hebl, L.,
2015, 102).
At the start of the appointment review the patients medical history
and updates, along with verifying that the patient has been taking
medications regularly and conditions are controlled. If the patient is taking a
blood thinner be sure to ask what their most recent INR was. This should
have been within 2 weeks of the appointment and the INR should be below
3.0 to treat (Unless they have an artificial heart valve then it can be up to
3.5). Check the blood pressure and it must be below 140/90 to treat. If it is
higher than this they should be referred directly to their physician (Hebl, L.,
2015, 102).
Hygiene will be critical to the overall health of the patient. The RDH
should customize the plan incorporating aides and techniques for the patient
that will help in reducing or eliminating inflammation. The best approach to
OHI is show-tell-do. Be patient, calm, empathetic, and encouraging. Work
with the patient and caregiver as a team to personalize a creative approach
for hygiene keeping it flexible. Always address the patient first, dont under
estimate the patients skills. Auxiliary aids could be items such as a grip or
ball on toothbrush to hold, floss holders, irrigators, and/or power brushes.
Recommend an at home fluoride treatment due to the higher risk of caries.
This could be a rinse, tablet, tray or rinse. Make the selection best for your
patients abilities. Motivate the patient by explaining the process of
periodontal disease and that we want to prevent tooth loss to ensure
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mastication and nutrition, preventing dentures, and extensive caries and


perio treatments. Stress the importance of keeping regular appointments
with hygienist and dentist to keep oral cavity healthy and to recognize any
changes to address them early (Wilkins, E. 2014, p.848-872).
Also critical to the patients overall health is nutrition counseling.
Recognize what specific nutrition guidelines they have been placed on by
their physician and build on it. For example with hypertension patient should
keep their sodium intake low and potassium intake high, including fruits and
veggies or a diabetic patient should increase their fiber intake and lower the
intake of sodium and cholesterol.
Prepare the dental unit based on the individualized needs. If patient
has weak facial muscles you may need a bite block, pillows for comfort may
be helpful, if need for wheelchair transportation set chair up appropriately
(Wilkins, E. 2014, p.848-872).
Some patients may have trouble with swallowing causing drooling that
can result in angular cheilitis. Closing the mouth and swishing may be
difficult which makes it necessary to keep the saliva ejector in use
throughout the whole appointment. An assistant may be able to help with
this to keep the patient comfortable, decrease the risk of aspiration, and
keep a clear view for scaling. Some may have loss of sensation resulting in
food packing and raising caries risk. Unilateral mastication and loss of tongue

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motion lessens the self-cleansing action also increasing risks of caries and
periodontal disease (Wilkins, E. 2014, p.848-872).

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References

Hebl, L. (2015). Dental Hygiene 3 Course Power Point, Kirkwood C.C.


Dennis, L. & Sen, S. (2015). The Journal of Professional Excellence,
Dimensions Dental Hygiene,
Reducing Stroke Risk (Volume 13, Number 4)
Wilkins, E.M. (2014). Clinical Practice of the Dental Hygienist (11th ed.)
Wynn, R., Meiller, T., & Crossley, H. (2014). Drug Information Handbook for
Dentistry (20th ed.)
U.S. Department of Health & Human Services, NIH (2014, March 26). What is
a Stroke? Retrieved
from www.nhlbi.nhi.gov/health/health-topics/topics/stroke#
Healthline Editorial Team (2011, February 1). History of a Stroke. Retrieved
from
http://www.healthline.com/health/stroke/history-of-stoke

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