American Journal of Infection Control 41 (2013) 149-54

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American Journal of Infection Control American Journal of

Infection Control

journal homepage: www.ajicjournal.org

Major article

Effect of oral hygiene interventions on opportunistic pathogens in patients

after stroke
Otto L.T. Lam PhD a, Anne S. McMillan PhD a, Lakshman P. Samaranayake DDS, FHKAM b,
Leonard S.W. Li FRCP, FACRM, FAFRM, FHKCP, FHKAM c, Colman McGrath PhD d, *
a
Oral Rehabilitation 4/F, Prince Philip Dental Hospital, Sai Ying Pun, Hong Kong
b
Faculty Office 6/F, Prince Philip Dental Hospital, Sai Ying Pun, Hong Kong
c
Department of Rehabilitation Medicine, Tung Wah Hospital, Sheung Wan, Hong Kong
d
Periodontology and Public Health 3/F, Prince Philip Dental Hospital, Sai Ying Pun, Hong Kong

Key Words: Background: Despite the role of the oral cavity as a reservoir of opportunistic pathogens for infection in
Mouth patients following stroke, the evaluation of the effects of oral hygiene interventions has been largely
Bacteria neglected.
Methods: This randomized clinical trial included 102 patients undergoing hospital-based rehabilitation
for stroke. Patients were randomized to one of 3 groups: oral hygiene instruction (OHI) only; OHI and
0.2% chlorhexidine mouth rinse twice daily; or OHI, 0.2% chlorhexidine mouth rinse twice daily, and
assisted brushing twice weekly. Oral samples were obtained at baseline and after 3 weeks for detection
of Staphylococcus aureus, aerobic and facultatively anaerobic gram-negative bacilli, and yeasts.
Results: Almost three-quarters (72.8%) of the patients harbored oral anaerobic gram-negative bacilli at
baseline, and more than half had detectable S aureus (56.8%) and yeasts (59.3%). Percentage frequencies
and viable counts of pathogens remained relatively stable during the course of the clinical trial, and no
significant differences were observed among the 3 patient groups.
Conclusions: In our study cohort, there was no significant difference in the effectiveness of the 3 different
oral hygiene interventions on the prevalence or viable counts of oral opportunistic pathogens.
Copyright Ó 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc.
Published by Elsevier Inc. All rights reserved.

Aerobic and facultatively anaerobic gram-negative bacilli
(AGNB), Staphylococcus aureus, and yeasts have been implicated as
primary etiologic agents in numerous hospital-acquired infec-
tions.1-3 The oral cavity serves as an important reservoir of these
opportunistic pathogens in hospitalized and medically compro-
mised individuals,4-6 including stroke survivors,7,8 and the oral
origin of these pathogens has been demonstrated in cases of aspi-
ration pneumonia9-13 and bacteremia.14-21 In addition, the oral
cavity may serve as a reservoir for cross-infection to other patients
and health care workers.22,23
Infection is an important cause of death after stroke, with re-
ported rates of chest infections of up to 22%.24 Chest infection, due
* Address correspondence to Colman McGrath, PhD, Prince Philip Dental Hospital,
Periodontology and Public Health, 3/F, 34 Hospital Road, Sai Ying Pun, Hong Kong.
E-mail address: mcgrathc@hkucc.hku.hk (C. McGrath).
Supported by the Committee of Research and Conference Grants of the
University of Hong Kong.
Registered with the Hong Kong Clinical Trial Register (HKCTR-1159) and the US
National Institutes of Health (NCT01265043).
Conflict of interest: None to report.
primarily to aspiration pneumonia, is associated with a 3-fold
increased risk of death and is one of the most common poststroke
sequelae necessitating hospital readmission.25 Poststroke pneu-
monia has been correlated with such factors as mechanical ventila-
tion, dysphagia, drowsiness, impaired protective reflexes, and stroke
severity, all of which increase the likelihood of aspiration of oral and
oropharyngeal secretions containing respiratory pathogens.26-28 In
addition, the presence of such pathogens may be fostered by poor
oral hygiene conditions in stroke survivors, deficiencies in oral self-
care caused by cognitive and sensory disturbances in coordination,
as well as stroke-related limb paralysis and its effects on manual
dexterity.29,30 Indeed, preliminary evidence suggests that oral
hygiene care may play a role in the prevention of pneumonia in
hospitalized and institutionalized patients.31
Traditionally, chemoprophylaxis with antibiotics and antifungal
agents has been the primary intervention for preventing and
treating bacterial and yeast infections, respectively. However, recent
reports have described the emergence of AGNB and S aureus with
resistance to multiple antibiotics,32,33 as well as the increasingly
frequent isolation of yeasts resistant to antifungal agents in

0196-6553/$36.00 - Copyright Ó 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
doi:10.1016/j.ajic.2012.02.020
150 O.L.T. Lam et al. / American Journal of Infection Control 41 (2013) 149-54
medically compromised individuals.34 Oral hygiene interventions
may have possible utility as an alternative or complementary
measure in combating these pathogens. Current evidence on the
effectiveness of oral hygiene interventions remains inconclusive,
however,35,36 and there is a pressing need for further investigation of
the efficacy of these interventions, especially in acute stroke survi-
vors, for whom no such studies have been reported.
Thus, the objective of the present study was to evaluate
the effectiveness of oral hygiene interventions (ie, oral hygiene
instruction [OHI], chlorhexidine [CHX] mouth rinse, and assisted
brushing) on oral opportunistic pathogens (i.e., S aureus, AGNB, and
yeasts) in hospitalized stroke survivors. A secondary objective was
to monitor the development of pneumonia during the in-hospital
rehabilitation period.
PATIENTS AND METHODS
This randomized clinical trial was conducted in a stroke reha-
bilitation ward at Tung Wah Hospital in Hong Kong. Patients were
previously stabilized for up to 7 days at Queen Mary Hospital before
being transferred to the rehabilitation ward. Eligibility criteria
included moderate to severe stroke (Barthel Index [BI] <70),37 age

50 years, and admission to the stroke rehabilitation ward up to 7
days earlier. Patients with mild stroke were excluded because they
had significantly less functional disability compared with those
with moderate to severe stroke and were usually discharged from
the rehabilitation ward within 7-10 days of admission. Other
exclusion criteria included edentulism, communication difficulties,
and presence of an indwelling nasogastric feeding tube.
This study was registered with both the Hong Kong Clinical Trial
Register (study ID: HKCTR-1159) and US National Institutes of
Health (www.clinicaltrials.gov; study ID: NCT01265043), and ethics
approval was obtained from the Institutional Review Board of the
University of Hong Kong (reference no. UW 06-380 T/1405).
Following provision of informed consent and notification of family
members and/or primary caregivers, patients were assigned (via
block randomization and a random number table) to receive 1 of 3
oral hygiene interventions after baseline assessment (Fig 1). This
assignment was performed by a research assistant using a color-
coding scheme, and only nursing staff had access to the color-
code key. The principal investigator was blinded to both the color
labels assigned to the patients and to the color-code key.
The 3 oral hygiene interventions were (1) OHI, involving
professional instruction on maintaining good oral hygiene using an
electric toothbrush (Oral-B AdvancePower 400 series; The Procter &
Gamble Company, Cincinnati, OH); (2) OHI and use of a CHX (Cor-
sodyl) mouth rinse (0.2%,10 mL) twice daily for a 3-week period; and
(3) OHI, use of CHX, and assistance with toothbrushing 2 times per
week for a 3-week period. Professional OHI was provided by
a registered dentist, and nursing care aides administered the CHX
mouth rinse and performed assisted brushing. Certified dental
hygienists provided an oral health training session for nursing aides,
consisting of a lecture (30 minutes) covering basic concepts of oral
health and disease, as well as a practical exercise on the adminis-
tration of assisted toothbrushing and the CHX mouth rinse.
Imprint and concentrated oral rinse techniques38 were used to
obtain oral microbiological samples from the patients before and
after interventions at baseline and 3 weeks, respectively. All spec-
imens were placed in an icebox after retrieval and transported to
the laboratory within 4 hours for processing. Denture-wearing
subjects removed their prostheses before rinsing. Oral rinse sam-
ples were plated onto Sabouraud dextrose agar (SDA; Oxoid Ltd,
Basingstoke, Hampshire, England), CHROMagar candida (CHRO-
Magar, Paris, France), mannitol salt agar (MSA; Difco Laboratories,
Detroit, MI), and MacConkey’s agar (Oxoid Ltd). After inoculation,
the MacConkey’s agar (Oxoid Ltd) plates were incubated for 24
hours at 37 C, and the SDA (Oxoid Ltd), CHROMagar, and MSA plates
(Difco Laboratories) were incubated for 48 hours at 37 C. After
incubation, plates were evaluated for isolates. Isolates on Mac-
Conkey’s agar were presumptively identified as AGNB by colony
morphology and the Gram stain method. Oxidase-positive isolates
were identified with API 20NE (bioMérieux, Marcy l’Etoile, France),
and oxidase-negative isolates were identified with API 20E (bio-
Mérieux). Yeasts were presumptively identified based on colony
morphology on SDA and CHROMagar plates and on Gram stain.
Identification to genus and species level was done using ID32C
(bioMérieux). S aureus was identified through examination of
colony morphology on MSA plates, Gram stain, the catalase test, and
the Slidex Staph Plus Kit (bioMérieux). Imprint cultures on SDA
were used for enumeration of yeast colony-forming units (cfu) only.
Patients’ medical records were examined for medications
received and the development of pneumonia during the clinical
trial. Swallowing disability was assessed using the Royal Brisbane
Hospital Outcome Measure for Swallowing.39
As part of a larger study examining clinical oral health, the initial
sample size for each treatment group was 40 patients per group
(120 subjects total) to detect a difference in plaque change score of
0.3 within and among the 3 groups with 80% power, an anticipated
10% dropout rate, and standard deviation set at 0.40.29 Complete-
case analysis was performed.40 Within-group comparisons of
median viable counts (cfu per milliliter) at baseline and at the end
of the clinical trial were performed using the Wilcoxon signed-rank
test. Change scores were calculated by subtracting posttreatment
scores from pretreatment scores. Change scores were compared
between groups using Kruskal-Wallis one-way analysis of variance
and the Mann-Whitney U test for individual pairwise comparisons.
The AGNB and S aureus viable counts used for statistical analyses
were those determined from oral rinse samples. The total yeast
viable counts used for statistical analyses were determined from
imprint samples and oral rinse samples plated on SDA. Individual
yeast family, genus, and species viable counts used for statistical
analyses were determined from oral rinse samples plated on
CHROMagar. Within-group comparisons of oral opportunistic
pathogen prevalence were done using the McNemar test. The c2
test was used to examine differences between groups in terms of
pathogen prevalence (ie, persistence, loss, acquisition, and absence)
and pneumonia.
Univariate analyses of possible explanatory factors for viable
counts of AGNB, S aureus, and yeasts were performed via linear
regression. Variables with a P value of .25 were entered into
a forward Wald multiple linear regression model for determination
of significant factors. Likewise, univariate analyses of possible
explanatory factors for AGNB, S aureus, and yeast presence were
also run through logistic regression. An explanatory model was
derived by entering variables with a P value of .25 into a logistic
regression analysis.
RESULTS
Approximately three-quarters of the patients harbored oral
AGNB at both time points. Predominant families of AGNB included
Enterobacteriaceae (46.9-54.3%) and Moraxellaceae (49.4%-39.5%).
Within the Enterobacteriaceae, Klebsiella pneumoniae pneumoniae
and Enterobacter cloacae were the most frequently isolated species,
with prevalences of 22.2%-38.3% and 17.3-25.9%, respectively. These
2 species were also the greatest in number, reaching viable counts
exceeding 104 cfu/mL. Acinetobacter baumannii was the most
prevalent Moraxellaceae species, with frequencies of up to 44.4%. A
total of 31 patients (38.3%) presented with identical species of
AGNB at both time points. Persistent species included A baumannii
 O.L.T. Lam et al. / American Journal of Infection Control 41 (2013) 149-54 151

Table 1
Comparison of oral opportunistic pathogen persistence, loss, acquisition, and absence between groups during the intervention period

Isolation before and after OHI þ CHX þ

Pathogen the intervention period OHI OHI þ CHX assisted brushing P value*
All opportunistic pathogens þþ 21 (84.0) 24 (92.3) 28 (93.3) .53
þ 3 (12.0) 1 (3.8) 0 .07
þ 1 (4.0) 1 (3.8) 1 (3.3) 1.00
 0 0 1 (3.3) .42
AGNB þþ 10 (40.0) 16 (61.5) 21 (70.0) .07
þ 7 (28.0) 3 (11.5) 2 (6.7) .08
þ 6 (24.0) 6 (23.1) 4 (13.3) .54
 2 (8.0) 1 (3.9) 3 (10.0) .77
S aureus þþ 10 (40.0) 7 (26.9) 10 (33.3) .61
þ 6 (24.0) 7 (26.9) 6 (20.0) .83
þ 5 (20.0) 4 (15.4) 5 (16.7) .94
 4 (16.0) 9 (34.6) 9 (30.0) .40
Yeastsy þþ 13 (52.0) 16 (61.5) 15 (50.0) .66
þ 1 (4.0) 1 (3.8) 2 (6.7) 1.00
þ 1 (4.0) 2 (7.7) 4 (13.3) .55
 10 (40.0) 7 (26.9) 9 (30.0) .58

NOTE. þþ indicates persistence over the duration of the intervention period; þ indicates loss over the duration of the intervention period; þ indicates acquisition over the
duration of the intervention period;  indicates absence over the duration of the intervention period.
*c2 test.
y
Prevalence as determined by a combination of oral rinse and imprint methods.

(18 patients), Pseudomonas aeruginosa (1 patient), K pneumoniae
pneumoniae (10 patients), Klebsiella oxytoca (1 patient), E cloacae (4
patients), Enterobacter aerogenes (1 patient), Citrobacter koseri (1
patient), and Serratia marcescens (1 patient).
S aureus was isolated from 56.8% of patients at baseline and in
50.6% at the 3-week review. Viable counts exceeded 105 cfu/mL. A
total of 27 patients (33.3%) had detectable S aureus at both time
points. Among yeasts, Candida albicans was the most commonly
isolated species, with frequencies of 46.9% at baseline and 53.1%
at the 3-week review. Viable yeast counts exceeded 105 cfu/ml.
Forty-two patients (51.9%) presented with identical species of
yeasts at both assessment time points. Persistent species included
C albicans (34 patients), Candida krusei (1 patient), Candida para-
psilosis (1 patient), Candida glabrata (8 patients), Candida tropicalis
(2 patients), Candida dubliniensis (5 patients), Saccharomyces cer-
evisiae (1 patient), Trichosporon asahii (1 patient), Debaryomyces
polymorphus (1 patient), Cryptococcus laurentii (1 patient), and
Pichia ohmeri (1 patient). A total of 23 patients (28.4%) had AGNB,
S aureus, and yeasts isolated at both baseline and the 3-week
review; however, less than half (43.5%) of these patients had all 3
groups of oral opportunistic pathogens at both time points.
No significant differences in the prevalence of AGNB, S aureus,
and yeasts were found between the 3 patient groups at baseline. No
obvious trends within groups were observed over the course of the
study for these 3 major pathogen groups. The percentages of
patients with persistence, loss, acquisition, and absence of oral
pathogens during the clinical trial are shown in Table 1. No signif-
icant differences in the major oral pathogens were seen between
the 3 treatment groups.
The 3 treatment groups demonstrated no significant differences
in median viable colony counts at baseline. In addition, no general
trends according to intervention type were observed. Total counts
of all opportunistic pathogens were significantly decreased in the
OHI group (P ¼ .032). No significant intergroup differences in
changes in oral pathogen counts were found.
Factors subjected to univariate analyses to test for association
with viable counts and prevalence of AGNB, S aureus, and yeasts
included gender, swallowing disability, dentures, antibiotic use,
nonsteroidal anti-inflammatory drug use, smoking, simvastatin
use, BI score, dental plaque score, gingival bleeding score, tooth
decay status (DMFT), pathogens at baseline, and other pathogen
groups. Final adjusted models for AGNB viable counts indicated
significant associations with yeast viable counts (adjusted R2 ¼
0.314; P < .001) at baseline as well as with AGNB viable counts at
the 3-week review (adjusted R2 ¼ 0.102; P ¼ .002). S aureus viable
counts were significantly associated with concurrent yeast viable
counts at the 3-week review (adjusted R2 ¼ 0.976; P < .001),
whereas yeast viable counts at baseline were significantly associ-
ated with both concurrent AGNB (P < .001) and antibiotic use
during the clinical trial (adjusted R2 ¼ 0.369; P ¼ .007). Denture
wearers were 3 times more likely to harbor yeasts (OR ¼ 3.40;
P ¼ .034) at baseline. At the end of the clinical trial, patients with
residual swallowing disability (OR ¼ 10.06; P ¼ .048) and yeasts
detected at the baseline assessment (OR ¼ 40.99; P < .001) were
10 times and 41 times more likely to harbor yeasts, respectively.
No patient developed pneumonia over the course of the clinical
trial. Two patients had developed pneumonia before baseline
assessment, which subsequently resolved with antibiotic treatment.
One patient developed pneumonia after completion of the clinical
trial. No patient received topical oral or systemic antifungal medi-
cation before the baseline assessment or during the clinical trial.
DISCUSSION
Almost three-quarters of stroke patients harbored oral AGNB at
baseline. This was higher than the prevalence rates (21.4%-22.9%)
reported by previous studies in hospitalized stroke survivors in
Hong Kong.7 Given that underlying illness and illness severity have
been proposed as important factors associated with the presence of
oral AGNB,41 possible explanations for the higher prevalence of oral
AGNB in our cohort might be our inclusion of patients with more
severe stroke, as well as the use of a more sensitive sampling
method (concentrated oral rinse). More than half of our patients
had detectable S aureus and yeasts, corroborating previous findings
in stroke survivors and other patient groups.7,42,43
A baumannii was the predominant AGNB species in the current
study, accounting for 61.0% of this pathogen group. This high
prevalence of A baumannii is of concern, given this organism’s
propensity for prolonged survival in hospital environments,
increasing drug resistance,44 and status as the only genus of AGNB
to be consistently associated with the increasing prevalence of
nosocomial infections, including pneumonias, urinary tract infec-
tions, and surgical site infections, over the past 2 decades in the
United States.45
152 O.L.T. Lam et al. / American Journal of Infection Control 41 (2013) 149-54
Fig 1. Recruitment of patients into the clinical trial.
Oral hygiene interventions were found to have little effect on
oral opportunistic pathogens during the in-hospital rehabilitation
period. In general, prevalence rates for the 3 pathogen types and
major species remained stable over the course of the clinical trial.
The findings observed in the group provided with OHI and electric
toothbrushes support the results reported by previous studies
demonstrating little impact of mechanical oral hygiene methods on
AGNB36 and S aureus,46 whereas results on oral yeasts have been
mixed.35
The effectiveness of 0.2% CHX mouth rinse against AGNB in other
medically compromised patient groups is unclear, with some studies
showing a lack of effect, others showing significant reductions in
AGNB, and still others reporting increases in this pathogen.36 One
study found that higher CHX concentrations (2% CHX solution applied
to mucosa, 15 mL, 4 times daily) were effective, although application
was associated with a high frequency of mucosal irritation.36
Few studies using 0.2% CHX against oral S aureus have been
published to date. Balfour et al47 reported dramatic clearance rates
of S aureus with the use of 0.2% CHX spray, along with patient
isolation, CHX body wash, and nasal mupirocin use in their cohort
of hospitalized patients. The majority of other studies using lower
CHX concentrations, however, have been hindered by low S aureus
prevalence at baseline or have been of short duration.46
Previous studies incorporating the use of 0.2% CHX mouth rinses
in oral hygiene regimens have also reported insignificant effects35;
however, those studies either had a low prevalence of yeasts at
baseline or were of short duration (less than 3 weeks). Other
studies using higher (0.5%) or lower (0.12%) CHX concentrations
over longer periods (2 months or longer) have reported significant
effects on yeast prevalence and viable counts.35 Thus, the absence
of significant effects on oral opportunistic pathogens in the current
study may have been due to an insufficient frequency of CHX use,
inadequate CHX concentrations, and/or the short duration of the
clinical trial. Extending the use of the commercial 0.2% CHX mouth
rinse in the current clinical trial beyond the manufacturer’s current
recommendations of twice-daily use (eg, to 4 times daily), or in-
house preparation of products containing higher CHX concentra-
tions for patients during their in-hospital rehabilitation period
merits consideration in future studies.
The lack of effect of the oral hygiene interventions on oral
opportunistic pathogens is interesting in light of an accompanying
reduction in dental plaque, especially in the 2 groups receiving the
CHX mouth rinse. This finding suggests that dental plaque might
not be the primary oral reservoir for such pathogens, which may be
able to persist in other niches (eg, mucosal surfaces) even in the
presence of good oral hygiene.
We also examined additional factors possibly associated with
the presence of oral opportunistic pathogens. Although antibiotic
therapy has been established as a contributory factor in yeast
colonization of the oral cavity,6 the interactions between AGNB and
yeast merit further consideration. Although it was possible that
illness severity was a common predisposing factor for the increased
levels of both AGNB and yeast colonization,41 synergy between
AGNB and yeasts also might have contributed, as suggested by
in vitro studies demonstrating coagglutination reactions between
these 2 pathogen groups,48 as well as increased adhesion of C
albicans to epithelial cells preincubated with AGNB.49
Concurrent yeast viable cell counts were the sole primary
explanatory variable for viable counts of S aureus at the end of the
clinical trial, supporting the results of 2 previous studies reporting
high frequencies of coculture of these 2 organisms from the oral
cavity,50 as well as bloodstream infections.51 Indeed, S aureus and C
albicans appear to interact synergistically,52 with up to 70,000-fold
increases in lethality observed when both species were coinocu-
lated intraperitoneally into mice.53
Our findings do not allow us to draw firm conclusions regarding
the role of the oral hygiene interventions on the absence of pneu-
monia, given the omission of a negative control group for ethical
reasons. Although previous studies on similar stroke subjects in
Hong Kong provided no data on the incidence of pneumonia,7,30
studies conducted in rehabilitative settings in other countries
have reported pneumonia rates of up to 11%.54 Therefore, the
absence of pneumonia in our cohort may have been due to the
small sample size.
Despite high prevalences of AGNB (72.8%-77.8%) and S aureus
(56.8%-50.6%) over the course of this clinical trial, identical species
of AGNB and persistence of S aureus at both time points was
demonstrated in only 38.3% and 33.3% of patients, respectively. We
did not genotypically evaluate the number of genetically identical
persisting strains, which should be considered by future investi-
gators. Thus, the possibility that the strains isolated at the end of
the clinical trial may have been acquired from other sources
external to the oral cavity should be borne in mind.
Although the patient’s own endogenous flora is acknowledged
as the primary source for opportunistic pathogens,55 the role of the
hospital environment as a reservoir for cross-colonization and
infection has been increasingly emphasized.56 Pathogens shed from
colonized patients may contaminate inanimate hospital surfaces
and the hands of health care workers, which then serve as sources
of cross-contamination to other patients. A factor in the survival of
AGNB, S aureus, and yeast in the hospital environment is these
organisms’ ability to persist on fomites for prolonged periods.57
Thus, the effectiveness of the oral hygiene interventions might
have been compromised by the constant challenge of pathogen
acquisition from the hospital environment. One factor that we did
not assess in the present study was denture hygiene, although all
 O.L.T. Lam et al. / American Journal of Infection Control 41 (2013) 149-54
patients with removable dentures were instructed to remove their
dentures before sleep, brush them under running water with soap,
and immerse them in water overnight in accordance with standard
recommendations.58
Another factor that we did not investigate in the current study
was the electric toothbrushes used by the patients. These might
have acted as reservoirs for oral opportunistic pathogen growth
and served as a secondary route for recolonization. Toothbrush
bristles provide a moist and conducive environment for microbes
and retain a significant amount of organic debris after use. A limited
number of studies have demonstrated that the toothbrush head can
provide a significant ecological niche for oral opportunistic path-
ogens.5,59 Patients were advised to rinse the brush head under
running water and allow it to dry in the open air (in accordance
with the manufacturer’s instructions). The degree of contamination
of toothbrushes and dentures, and their role as reservoirs for
colonization of the oral cavity by opportunistic pathogens, warrant
consideration in future studies.
In conclusion, in our cohort, oral hygiene interventions using
OHI, 0.2% CHX mouth rinse, and assisted brushing were not effec-
tive in reducing the frequency or viable counts of oral opportunistic
pathogens. Although our results are limited by a small sample size
and short-term follow-up, this study provides a baseline for future
research aiming to substantiate the effectiveness of oral hygiene
measures against oral opportunistic pathogens in stroke survivors
during their hospitalized recovery period.
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