stroke is characterized by a sudden , non - convulsive , focal 
 neurological deficit caused by a brain lesion stemming from a non - traumatic vascular 
 mechanism due to arterial or venous embolism leading to cerebral ischemia or hemorrhage2 .
the most common manifestations of stroke are sensory , cognitive and motor impairments , such 
 as hemiparesis , spasticity , an abnormal movement pattern3 and physical deconditioning4 , 
 5 .
any force exerted on the jaws should 
 be identified as a triggering factor of a functional imbalance in the masticatory 
 system6 . according to saliba
et al.7 , upper limb impairment is one of the most 
 common complaints of stroke survivors with hemiparesis . it is estimated that 70% of such 
 individuals suffer residual disability that compromises dexterity during activities of daily 
 living8 .
individuals with hemiparesis 
 exhibit slow movements during activities that involve the upper limbs , such as reaching and 
 grasping , due to limited range of motion , segmented movements and a lack of coordination 
 among the joints4 , 9 .
normal upper limb function involves the capacity for directed reach , grasping and 
 manipulation of objects , which make up the motor skills required for the performance of 
 activities of daily living6 that allow an 
 individual to lead an independent life with self - esteem8 .
the execution of proper oral hygiene , for example , requires 
 adequate motor control of the upper limbs9 .
compromised upper limb function exerts an impact on the degree of 
 disability experienced by stroke survivors , with a significant influence on functional 
 performance and negative consequences regarding personal , familial and social relationships 
 as well as quality of life10 . despite the gradual return of motor function resulting from a combination of spontaneous 
 recovery and physical therapy ,
the use of the paretic limb is often less than its normal 
 potential in daily living11 .
depending on 
 the degree of upper limb impairment , the maintenance of adequate oral health among stroke 
 survivors can be hindered3 , 8 .
moreover , inadequate oral hygiene can compromise both oral 
 health and quality of life . considering the high prevalence rates of functional limitations to the paretic arm7 ,
the aim of the present study was to 
 evaluate the relationship between upper limb impairment and oral health impact in 
 individuals with hemiparesis stemming from a stroke .
this study received approval from the local human research ethics committee under process 
 number 259.239 .
all participants received an explanation about the study and authorized 
 participation by signing a statement of informed consent in compliance with resolution 
 466/2012 of the brazilian national board of health .
the participants were recruited from the 
 physical therapy clinic of nove de julho university ( brazil ) . a descriptive ,
cross - sectional study was conducted of a sample of 27 stroke survivors with 
 complete or partial hemiparesis with brachial or crural predominance .
individuals with cognitive deficit , those with 
 dentofacial deformities , those receiving dental treatment and those with sensitivity 
 abnormalities or quadriparesis were excluded from the study . the 14-item short version of the oral health impact profile ( ohip-14)12 was used to evaluate perceptions of oral health13 .
this questionnaire has seven subscales , 
 each with two questions : functional limitation , physical pain , psychological discomfort , 
 physical disability , psychological disability , social disability and social handicap .
however , to eliminate 
 limitations related to the function of the paretic upper limb , the questionnaire was 
 administered in interview form ( the researchers read the questions aloud and marked the 
 respondents answers ) . the brazilian version of the stroke specific quality of life scale ( ssqol - brazil)14 , 15 
 was used to evaluate perceptions regarding quality of life .
this scale has 49 items 
 distributed among 12 subscales ( energy , family roles , language , mobility , mood , personality , 
 self care , social roles , reasoning , upper extremity function , vision and work / productivity ) . 

each item has five response options referring to function in the previous week . the score of 
 each item ranges from 1 to 5 points and the total ranges from 49 ( worst perception of 
 quality of life ) to 245 ( best perception ) . in the present study ,
only the upper extremity 
 function subscale was employed to analyze its association with oral health impact .
although 
 upper extremity function on this questionnaire is evaluated based on actions such as 
 fastening a button and opening / closing a zipper , ssqol - brazil was chosen for use in the 
 present study due to the lack of specific questionnaires in the literature for the 
 evaluation of upper limb function in relation to oral self - care and even the function of 
 feeding oneself .
the shapiro - wilk s 
 test was used to determine whether or not the data had a normal distribution .
pearson s correlation coefficients were calculated to 
 determine the magnitude , direction and significance of associations between variables 
 related to upper limb function and oral health impact .
the strength of the associations was 
 classified as weak ( correlation coefficient : 0.1 to 0.3 ) , moderate ( correlation coefficient : 
 0.4 to 0.6 ) or strong ( correlation coefficient : 0.7 to 1 ) . a level of significance of 5% ( p 
 <
twenty - seven individuals with hemiparesis stemming from a stroke participated in the 
 present study .
the female accounted for 37.1% ( n = 10 ) of the sample and the male accounted 
 for 62.9% ( n = 17 ) .
the mean age of the subjects was 60.5  12.7  years ( range : 30 to 
 85  years ) and the mean time since the occurrence of stroke was 28.5  29.6 months ( range : 2 
 to 108 months ) .
a total of 51.8% of the sample ( n = 14 ) had right side hemiparesis and 48.2% 
 had left side hemiparesis ; 63% ( n = 17 ) had complete hemiparesis and 37% ( n = 10 ) had 
 partial hemiparesis ; 55.5% ( n = 15 ) had brachial predominance and 44.4% ( n = 12 ) had crural 
 predominance .
a statistically significant association was found between the upper extremity function 
 subscale of the ssqol - brazil and the impact of oral health evaluated using the ohip-14 , with 
 a strong correlation found for the physical pain subscale ( 0.707 ) , moderate correlations 
 with the functional limitation ( 0.502 ) , psychological discomfort ( 0.474 ) , physical 
 disability ( 0.461 ) , social disability ( 0.549 ) and social handicap ( 0.555 ) subscales , as 
 well as a weak correlation with the psychological disability subscale ( 0.393 ) .
all 
 correlations were negative ( table 1table 1.correlations between the upper extremity function ( uef ) subscale of ssqol - b and 
 ohip-14 scales among individuals with hemiparesis stemming from a strokeuef ( ssqol ) x ohip-14nrfunctional limitation270.502*physical pain 270.707*psychological discomfort270.474*physical disability270.461*psychological disability270.393*social disability270.549*social handicap270.555*ohip-14270.722 * ) . for the evaluation of oral health impact on quality of life ,
the responses received codes , 
 which were multiplied by the respective weight of the question : 0 = never or 
i do nt know  ; 
 1 = hardly ever ; 2 = occasionally ; 3 = fairly ofen ; and 4 = very often .
thus , the maximum 
 score for each dimension was 4 points and the impact of each dimension was classified as 
 weak , moderate or strong .
a score of 0 to 9 indicated 
 weak impact , 10 to 18 indicated moderate impact and 19 to 28 indicated strong impact ( i.e. , 
 higher scores denoted greater negative oral health impact on quality of life ) . the same was 
 true for each dimension , for which the scores ranged from 0 to 4 . among the 27 individuals in the present sample , the mean overall ohip-14 score was 4.63 
 with a standard deviation ( sd ) of 6.6 ( range : 0.00 to 24.27 ) .
oral health status exerted a 
 weak impact on the quality of life of the subjects ( table 2table 2.distribution of impact of oral health conditions per ohip-14 subscale among 
 individuals with hemiparesissubscalemeansdimpactfunctional limitation0.741.2weakphysical pain0.661.1weakpsychological discomfort1.061.3weakphysical disability0.570.9weakpsychological disability 0.671.0weaksocial disability0.471.1weaksocial handicap0.451.0weaksum of subscales 4.636.6weak ) . analyzing the ohip-14 scores with regard to the impact of oral health on quality of life , 
 the most frequent classification was weak impact ( n = 24 ; 88.8% ) , with small rates of 
 moderate ( n = 1 ; 3.70% ) and strong ( n = 2 ; 7.40% ) impact ( table 3table 3.classification of answers to ohip-14 questionnaire according to the general 
 impact of oral health on quality of lifeimpactn%weak2488.8moderate13.70strong27.40total27100 ) .
in the present study , we found that compromised upper limb function exerts an impact on the 
 degree of disability experienced by stroke survivors . in the present study , hemiparesis with 

brachial predominance affected 55.5% of the sample , which may explain the strong association 
 found between physical pain and upper limb function .
hemiparesis leads to instability in 
 movements of the trunk and limbs , thereby compromising performance of activities of daily 
 living , such as oral hygiene , which depend on adequate motor control of the upper limbs16,17,18,19 . 

hemiplegia may impact on a person s ability to carry out oral care procedures and reduce 
 mobility after stroke20 .
age is another factor that may have influenced the subjects ability to perform self - care 
 in the present sample , as the mean age was 60.5  years .
silvestre et al.21 reported approximately 40% of individuals aged 60  years or 
 older need some type of assistance to perform at least one instrumental activity of daily 
 living and 10% need assistance to perform basic tasks , such as bathing , dressing and other 
 aspects of self - care . according to hunt et al.22 and slade et al .
the combination of the negative consequences of ageing and stroke 
 leads to a substantial reduction in quality of life . the total ohip-14 score in the present study was low ( 4.6 points ) .
in contrast , reed et 
 al.23 found that 137 older adults at an 
 extended care facility had a poor perception of their oral health status .
many older adults 
 seem not to be bothered by poor oral health , which demonstrates a certain cultural 
 resignation24 .
indeed , oral problems 
 are often minimized in comparison to other adverse health conditions25 .
numerous clinical conditions , such as poor posture and 
 malocclusion may be related to the muscles of mastication , the temporomandibular joint and 
 associated structures , and may change orofacial functions26 .
thus , when evaluating quality of life , older adults often perceive 
 poor oral health as normal or acceptable for someone at an advanced age . despite this 
 resigned attitude , the association between oral health and quality of life indicates that 
 oral problems exert a negative impact on the emotional well being of this population . in the 
 present study
, a negative correlation was found between social disability ( ohip-14 ) and 
 quality of life ( ssqol - b ) , as individuals with higher social disability scores stemming from 
 oral problems had lower quality of life scores .
these findings are in agreement with data 
 reported by marin et al.27 and tatematsu 
 et al.28 , who stated oral pain and 
 problems with eating , chewing , smiling and speaking tend to affect an individual s wellbeing 
 substantially . for individuals with hemiparesis , adequate oral health may mean reintegration into society 
 and a significant improvement in quality of life therefore , the rehabilitation of the 
 paretic upper limb and orofacial function can lead to an improvement in the quality of life 
 of such individuals .
compromised upper limb function and self - perceived poor oral health , whether due to 
 cultural resignation or functional disability , exert a negative impact on the quality of 
 life of individuals with hemiparesis stemming from a stroke .
 [ purpose ] the aim of the present study was to evaluate the relationship between upper 
 limb impairment and oral health impact in individuals with hemiparesis stemming from a 
 stroke . [ subjects and methods ] the study subjects were conducted with a sample of 27 
 stroke survivors with complete or partial hemiparesis with brachial or crural 
 predominance . 
 the 14-item short version of the oral health impact profile was used to 
 evaluate perceptions of oral health . 
 the brazilian version of the stroke specific quality 
 of life scale was used to evaluate perceptions regarding quality of life . 
 [ results ] a 
 statistically significant association was found between the upper extremity function 
 subscale of the ssqol - brazil and the impact of oral health evaluated using the ohip-14 , 
 with a strong correlation found for the physical pain subscale , moderate correlations with 
 the functional limitation , psychological discomfort , physical disability , social 
 disability and social handicap subscales as well as a weak correlation with the 
 psychological disability subscale . analyzing the ohip-14 scores with regard to the impact 
 of oral health on quality of life , the most frequent classification was weak impact , with 
 small rates of moderate and strong impact . 
 [ conclusion ] compromised upper limb function 
 and self - perceived poor oral health , whether due to cultural resignation or functional 
 disability , exert a negative impact on the quality of life of individuals with hemiparesis 
 stemming from a stroke . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION