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Medically Compromised Patients Supporting Your Practice

How do you manage people with Parkinson’s disease in the dental setting?

Untitled-3This question was submitted by a general dentist:

Do you have any suggestions for managing Parkinson’s disease in a clinical setting to enable a safe hygiene and restorative outcome. I have a patient with advancing motor and swallowing/breathing difficulties that is not manageable for the hygienist presently. Restorative procedures would be equally impossible.

Dr. Alison Dougall from IADH and Dr. Suham Alexander provided this quick initial response: 

Parkinson’s disease is the second most common chronic and progressive neurodegenerative disease involving the neurons responsible for producing dopamine. Parkinson’s affects approximately 1 in 1000 people in the general population. The peak onset is between 55 and 66 years of age however, a form of the disease has been known to occur in teenagers. An average dental practice of 2000 patients may predict that up to 4 of their patients will be diagnosed with Parkinson’s disease.

The disease is characterized by motor disturbances such as resting tremors, muscular rigidity, bradykinesia and postural instability. There can also be varying degrees of cognitive impairment, mood disturbances and in some instances, psychosis which is related to dopaminergic medications may occur.

In terms of oral health, patients may experience the following problems:

  • Xerostomia
  • Burning mouth
  • Root caries
  • Dysphagia and drooling
  • Difficulty in maintaining oral hygiene

Dental Management and Treatment Considerations 

Managing a patient with Parkinson’s involves minimizing any potential adverse outcomes of tremors and muscle rigidity as well as avoiding drug interactions.

One of the most important treatment considerations for the Parkinson’s patient is open communication concerning his/her oral health and the oral implications of the disease. Muscle rigidity and tremors are contributing factors to the patient’s poor oral hygiene and as such, the dental team must assess the patient’s ability to keep his/her mouth clean. It is important to empower the patient to maintain good oral hygiene through various toothbrushing aids and adaptations (eg. electric, aspirating toothbrushes) which will enable self-care, fluoride rinses toothpastes with higher concentrations of fluoride as well as diet and nutrition counselling. Patients may be scheduled more frequently for recall visits to help maintain oral hygiene. Personal support workers and caregivers should also be instructed in oral hygiene techniques and its importance for the patient. Whenever feasible, self-management is preferable; however, it may be necessary to train and collaborate with other caregivers to ensure the patient’s oral hygiene is maintained as best as possible.

The patient’s treatment plan should be customized according to the level of motor and cognitive impairment that is present. However, it is important to ensure pragmatic treatment planning is done appropriately early once the patient has been diagnosed with Parkinson’s, where possible. This will ensure that the patient’s dentition is well-restored and cared for on a regular basis given the care is harder to provide in later years or stages of the disease.

Patient appointments should be booked at the time of day that their medications will have the optimal effects, usually 2-3 hours after taking them. Soft arm restraints and/or sedation may mitigate the presence of tremors or undesired movement during treatment. Additionally, it may be prudent at times to cradle the patient’s head for stability. The use of mouth props may be indicated as well. The dental health team must also take care to avoid needle-stick injuries to the operator, patient and/or auxiliary team member during anesthetic delivery. In some situations, a small dose of midazolam may be given to patients to control tremors. Practitioners should be also be aware that many anti-Parkinsonian medications may act as CNS depressants and any sedatives prescribed for dentistry may have additive effects.

With respect to medications, many COMT inhibitors such as Tasmar, Comtan have the potential to interact adversely with epinephrine administered via local anesthetic. As such, epinephrine should be limited to concentrations of 1:100,000 in these patients and no more than 2-3 carpules of anesthetic should be administered.

Airway protection, such as the use of rubber dam, should be considered given the impaired swallowing reflexes in this patient population. This will also minimize the risk of pulmonary aspiration of saliva and debris.  To manage salivary secretions during restorative treatment, additional suction behind the rubber dam is beneficial Along with frequent rests for the patient.During treatment, the chair should not be reclined more than 45°. In advanced stages of Parkinson’s disease, the chair may need to be kept upright during treatment and the chin in a tucked position.

The dental team must also be aware that the fall risk in Parkinsonian patients is twice that of the average person due to impaired motor skills as well as non-motor skills including, but not limited to:

  • hypotension from sitting or lying down
  • fatigue and exhaustion due to disturbed sleep patterns
  • impaired executive functions which leads to distraction and inattention
  • blurred or double vision
  • side-effects from medications – dyskinesia, retropulsion and propulsion

As such, it is essential to provide physical support to these patients as determined by the severity of the disease when required.

Salivary substitutes may be prescribed for this patient population as xerostomia secondary to medication regimes can occur. Topical fluoride for dentate patients will also be beneficial in preventing root caries. Conversely, in other patients, sialorrhea or drooling is another issue caused by pooling saliva in the mouth, forward head posture and the impaired swallowing reflex. This can cause significant social embarassment and emotional consequences for patients. Fortunately, this can be temporarily managed (~1.5-6 months) with the injection of botulinum toxin into the salivary glands. Radiotherapy is also considered useful in treating the sialorrhea but is irreversible and carries increased caries risk. In some cases, scopolamine patches are also prescribed to dry secretions; however, again this results in xerostomia and requires protective topical fluoride regimes 

Patients who wear dentures should be instructed in proper care for their prosthesis with maximum retention obtained via baseplate extension and/or implants. Additionally, it may help to create grooves in the denture surface to allow patients with impaired motor skills to manipulate them during insertion and removal. 

References 

  1. Little JW, Falace DA, Miller CS, Rhodus NL. Little and Falace’s Dental Management of the Medically Compromised Patient. 2013. Elsevier Mosby. St. Louis, MO.
  2. Dougall A, Fiske J. Access to special care dentistry, part 9.  Special care dentistry for older people. British Dental Journal. 2008; 205: 421-434.
  3. Parkinson’s Disease Foundation [Internet]. New York. Parkinson’s Disease Foundation. c2014 (cited 2014 Dec 19). Fall Prevention Strategies for People Living with Parkinson’s. [about 1 screen]. Available from: http://www.pdf.org/en/fall09_fall_prevention
  4. International Association for Disability and Oral Health [Internet]. Gennep, Netherlands. IADH. c2013 (cited 2014 Dec 19). Dysphagia: tips to make dental management easier to swallow. [about 47 slides]. Available from: http://iadh.org/wp-content/uploads/2014/03/Dental-Management-of-Dysphagia.pdf

Dr Alison Dougall qualified from the University of Leeds and trained in Special Care Dentistry at the Eastman Dental Institute, London. She is a Consultant in Medically Compromised Patients and teaches Special Care Dentistry at undergraduate, post-graduate and Doctorate levels at Dublin University Dental Hospital and is currently Editor of the International Association of Disability and Oral Health (iADH) and co-chair of the IADH Education Committee, The Dental Chair of the World Federation of Haemophilia Medical Advisory Board and immediate Past President of the Irish Society for Disability and Oral Health. She has published widely in the topic of Special Care Dentistry and is International Invited Speaker and is a member of the Academic Reference Panel for Department of Health, Ireland.

4 Comments

  1. Dental Pune January 4, 2019

    I guess managing any type of patient is something all dentist go for.I really liked the article how you explained how to deal with it.

    Reply
  2. Dental Enthusiast January 14, 2019

    As a dentist one needs to learn to deal with various types of patients. Awesome article!!

    Reply
  3. Deepika January 15, 2019

    Very helpful article…

    Reply
  4. Prabhu June 26, 2019

    Thanks for sharing the great post.

    Reply

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