Brushing our teeth is something many of us do automatically, morning and night, without stopping to think. For most people, it is an unremarkable part of personal hygiene. As a dentist working with people with complex health needs, I am constantly reminded that this task can become profoundly difficult after a life-changing event such as a stroke, and when mouth care standards slip, the consequences can be serious.
Our research focuses on the oral health of people recovering from a stroke. Through my clinical work and involvement in national NICE stroke rehabilitation guidelines, I have seen firsthand how oral health is often overlooked during rehabilitation, despite its importance for comfort, dignity and overall health. This blog explores why oral care matters after stroke, why powered toothbrushing may help, and why we urgently need better evidence in this area.
Oral health after stroke: a hidden challenge
Stroke is one of the leading causes of death and long-term disability worldwide. Advances in acute medical care mean that more people are surviving stroke than ever before, but many are left with physical, cognitive or communication difficulties. These changes can have a direct impact on everyday self-care tasks, including brushing teeth.
After a stroke, people may experience reduced hand strength and coordination, fatigue, sensory changes or problems with planning and sequencing tasks. Swallowing difficulties are common, and diets are often modified to softer foods. Many people also develop dry mouth, often as a side effect of medications. Together, these factors create the perfect conditions for food debris and dental plaque to build up quickly.
In my clinical experience, even people who appear to have made a “good” recovery can struggle to return to their previous oral hygiene routines. Brushing may take longer, feel uncomfortable or be avoided altogether. Over time, this can lead to gum disease, tooth decay, pain and infection.
Why oral health matters for recovery
Poor oral health is not just a dental issue. There is strong evidence linking periodontal (gum) disease, a chronic inflammatory condition, with systemic diseases such as diabetes, cardiovascular disease and cognitive disease. For people who have had a stroke, one complication is particularly important: post-stroke pneumonia.
Post-stroke pneumonia is the most common medical complication following stroke and is associated with high mortality. One of the key causes is aspiration of bacteria from the mouth into the lungs. The mouth – including the teeth, gums and palate – acts as a reservoir for bacteria. If oral hygiene is poor, these bacteria can be inhaled, especially in people with swallowing difficulties or a reduced cough reflex.
This is why effective toothbrushing and cleaning of the mouth are so important after stroke. Yet research consistently shows that mouth care in hospitals and rehabilitation settings is often suboptimal. Staff may receive little training, time pressures are significant, and oral care products are not always readily available.
Where the evidence falls short
I was part of the expert group that contributed to the oral health section of the UK National Clinical Guideline for Stroke published in 2023. One of the most striking findings from this work was how limited the evidence base is. There are no consistent standards for mouth care after stroke, and much of the guidance relies on expert opinion rather than robust research.
Many guidelines include general advice such as “provide regular mouth care”, but offer little practical detail. Much of the published research focuses on antimicrobial mouthwashes rather than on how people actually brush their teeth, even though mechanical plaque removal is the foundation of good oral health.
This gap becomes particularly important during rehabilitation, when people are encouraged to regain independence. At this stage, patients may no longer receive hands-on help with mouth care but may still struggle to brush effectively.
Could powered toothbrushing help?
Powered toothbrushes have changed significantly in recent years. Modern brushes are lighter, easier to hold and often include features such as oscillating brush heads, timers and pressure sensors. For someone with reduced dexterity or fatigue after stroke, these features may make brushing easier and more effective. They may also support family members or carers who are helping with mouth care.
National guidance is beginning to reflect this potential. NICE stroke rehabilitation guidance published in 2023 recommends assessing oral hygiene after stroke and encouraging twice-daily brushing, using an electric or battery-powered toothbrush if needed. However, NICE also highlights the need for further research into whether powered toothbrushes are acceptable and effective for people after stroke.
At present, there is no clear evidence that one type of toothbrush is superior for people with physical or cognitive impairments. This uncertainty is frustrating for clinicians and patients alike.
Our feasibility study
In response to these gaps, my current research includes a feasibility study at the Royal Hospital for Neurodisability, a specialist neurorehabilitation centre in south-west London. Many patients admitted for stroke rehabilitation have spent long periods in acute hospital care where they were unable to brush their own teeth.
As rehabilitation progresses, patients are encouraged to take back control of personal care, including mouth care. This study explores whether introducing powered toothbrushing, alongside person-centred oral health education, is feasible and acceptable at this stage of recovery.
The education component is tailored to each individual, taking into account their abilities, preferences and support network. Family members and carers are involved wherever possible, recognising their crucial role after discharge.
Looking ahead
Oral health should not be an afterthought in stroke rehabilitation. It affects comfort, confidence, dignity, and potentially survival. By paying attention to something as simple as how people brush their teeth, we may be able to reduce complications such as pneumonia and improve the quality of life for stroke survivors.
My hope is that this feasibility work will lay the groundwork for larger studies and, ultimately, clearer guidance. As researchers and clinicians, we have an opportunity to shine a spotlight on oral health and ensure it becomes an integral part of holistic stroke care – not just in the hospital, but long after people return home.