These data provide novel evidence about dental anxiety and oral health in first-time stroke survivors. The key finding to emerge was that, although there was no evidence of poorer oral health or increased dental anxiety up to 18 months following stroke, a higher level of dental anxiety was significantly and substantially correlated with poorer oral health in this group.

As noted previously, it had been anticipated that stroke survivors would have poorer oral health given that a recent systematic review concluded that oral health problems are more common following acquired brain damage [5]. However, in many of the studies contributing to this review, microbiological or biochemical aspects of oral health were assessed, and these are more sensitive to early deterioration than the self-report measure used here. Additionally, many of the contributing studies were completed in clinical care environments and included stroke survivors who had a longer chronicity and/or who had suffered severe, or recurrent strokes. A key conclusion of Kothari et al.’s [5] review was that hospitalisation itself was linked to more deteriorated oral health. Perhaps most importantly, many of the oral health problems indexed by the measure used here (such as tooth mobility and tooth cavities) only occur after a lengthy period of deterioration. Not only were all the stroke participants that contributed to the present study first-time stroke survivors who had returned to their own homes, but all were also tested only approximately one year following this initial stroke (average chronicity was 13.64 months, SD = 2.29).

Most importantly here, although overall stroke survivors did not differ from controls in their degree of dental anxiety, the stroke (but not the control group’s) level of dental anxiety was significantly correlated with their oral health. Indeed, the magnitude of this effect qualified as a large effect even after covarying for broader negative affect and satisfaction with life. This indicates that it is dental anxiety specifically and not broader psychopathology that is related to oral health following stroke. It also provides preliminary support for the possibility that, even when dental anxiety is no more frequent in this clinical cohort than in non-clinical controls, when it does present it may have more serious consequences.

Broader literature shows how dental anxiety can, over time, establish a vicious cycle, whereby the initial avoidance of dental treatment may lead to treatment being delayed until the point that dental pain can no longer be endured - at which point the oral health deterioration may have become so severe that more invasive, painful treatment is required. This then leads to a reinforcement of dental fear, and future avoidance of treatment-seeking. [8, 10]. Although dental anxiety would therefore be of concern in any group, the present study suggests that it may be particularly problematic following stroke. It is cautiously suggested that this may be because broader losses in both cognitive and physical function that are caused by stroke make it more challenging to engage in good oral hygiene and to access external oral health care. Dental anxiety may therefore be especially problematic since it will presumably reduce motivation to try and overcome these other challenges. Future work is now needed to directly test this possibility using longitudinal research methods, and to also see if the strong relationship between dental anxiety and oral health identified following stroke is also evident in other clinical groups that present with chronic cognitive and/or physical limitations.

Finally, some limitations need to be acknowledged. First, although the present study was adequately powered to detect largesized effects, it was underpowered to detect weaker ones, and moving forward larger sized samples are therefore important. Related to this point, because of the sample size, we treated stroke here as a single homogeneous group, yet there are many differences between stroke survivors that might potentially influence their vulnerability to dental anxiety as well as oral health. This includes not only clinical characteristics of the stroke (type, location, and size), but also factors that influence recovery (such as support networks, and financial resources). Future research should also seek to consider this broader heterogeneity in trying to understand the relationship between dental anxiety and oral health following stroke.