24.3 Movement disorders Flashcards
Define athetosis, dystonia, tics, chorea, tremor, restless leg syndrome and ataxia.
What is cerebral palsy?
An umbrella term for non-progressive neurological and physical disabilities caused by damage or a lesion to a child’s brain early in life or in utero.
It is the most common congenital cause of physical impairment.
What is the range of disability with regards to cerebral palsy?
- Monoplegia: affects 1 limb
- Paraplegia: affects 2 limbs
- Quadriplegia: affects 4 limbs
- Hemiplegia: affects limbs on one side
How is brain damage caused in cerebral palsy?
Mainly due to hypoxia, trauma or infection.
E.g. a long and difficult birth.
What are the risk factors for cerebral palsy?
- Maternal age lower than 20 or above 35
- Pre-eclampsia
- Prenatal irradiation
- Pre-natal infections e.g. rubella, syphilis, cytomegalovirus
- Peri-natal risks (during birth) e.g. traumatic or breach birth, prolonged delivery
- Post-natal infections e.g. meningitis, encephalitis
What are the 5 types of cerebral palsy?
- Spastic CP (most common, 77%)
- Athetoid cerebral palsy
- Ataxic CP
- Hypotonic CP
- Mixed type
What are the features of cerebral palsy?
- Visual, hearing and speech impairments
- May have a learning disability
- Weakness in one or more limbs, foot that drags as they walk
- Non-progressive
- Secondary complications can occur
- Epilepsy may also be present
- Dysphagia
- Excessive drooling
- Poor control over hand and arm movements
- Abnormal gait
What secondary complications might someone with cerebral palsy experience?
- Respiratory complications due to dysphagia
- Gastric reflux
- Constipation due to reduced muscle tone
- Bladder and kidney infections
- Pressure sores on the skin
- Peri-oral skin issues due to drooling
- Musculo-skeletal issues e.g. arthritis, dislocations, deformities
What dental considerations are there with regards to people with cerebral palsy?
- Developmental abnormalities: maxillary arch often tapered, labially inclined incisors, malocclusion may be more common due to poor oromuscular co-ordination, lack of lip seal and tongue thrust
- Uncontrolled movement: spacicity of TMJ musuclature, spontaneous jaw dislocation, spontaneous subluxation of TMJ, facial grimacing
- Bruxism and tooth wear due to uncontrolled movement of TMJ muscles, may be exacerbated by reflux
- Periodontal disease: mouth breathing, anti-epileptic medication can cause gingival enlargement, increased food retention, poor mobility so poor OH, if they are PEG fed they will have lots of calculus
- Caries: food retention, struggle with OH, dietary supplements may be cariogenic
- Truama: increased risk of falls and seizures
- Xerostomia: reduced salivary flow rate and lower buffering capacity, medication may also cause xerosotmia
- Sialorrhea: excessive drooling
How can sialorrhea be managed?
- Anticholinergic drugs e.g. glycopyrronium bromide
- Botox can be used, effects last 2-6 months
How may cerebral palsy affect dental treatment?
- Setting depends on severity, some pts can be treated in primary care
- Consider ability to consent, CP doesn’t mean someone doesn’t have the intellect to consent always
- Sedation may be required, jerky movements can affect treatment
- Support pts head with pillow
- GA may be needed
- Hoist in hospitals or specialist dental practice to get pt into chair
What is Huntington’s disease?
A hereditary neurodegenerative disorder.
- Huntington gene on chromosome 4
- Autosomal dominant
- Causes damage to the basal ganglia and cerebral cortex
- Symptoms develop aged 30-50
What are the signs and symptoms of Huntington’s?
- Early symptoms include uncontrollable muscle movements, clumsiness, stumbling when walking, lack of concentration, mood and personality changes, depression, aggression, problems remembering new facts, difficulty making decisions and driving
- As disease progresses, speech becomes slurred, swallowing and eating difficulties arise, walking becomes difficult and patient may require a wheelchair
- Cognitive decline can result in dementia
- Duration of disease is 10-30 years after diagnosis
- Triad of symptoms: movement, cognition, mental health
What is the management for Huntington’s?
- No specific treatment
- Medicines can help to improve quality of life
- Antipsychotic/neuroleptic medicines help muscle movement and mood changes
- Antidepressants can stabilise the mood e.g. fluoxetine, sertraline, citalopram, quetiapine, olanzapine, risperidone
- Speech and language therapy to help speech and swallowing issues
What are the dental considerations with regards to patient’s with Huntington’s?
- Oral hygiene affected by poor manual dexterity and cognitive decline
- As condition progresses, capacity to consent may be lost
- Communication difficulties, struggle to understand complex sentences
- Mobility, will eventually require a wheelchair
- PEG feeding = calculus
- Trauma to soft tissues
- Medications can cause xerostomia, xerostomia can lead to candida
- Open mouth posture can exacerbate xerostomia
- Vomiting and reflux can damage dentition and cause ulcers
How may Huntington’s affect dental treatment?
- May be treated by GDP but could require referral to community dental services
- Dentate patients should be prescribed high fluoride toothpastes and have increased prevention e.g. fluoride varnish, saliva replacement gels
- Advanced complex treatments (implants, crowns and bridges) may be best tx planned with a specialist due to more complex long term maintenance requirements
- Aspiration pneumonia is a risk at later stages (use good suction, rubber dam)
- Simple treatments may be able to be provided in an electric wheelchair
- If movements cause risk to practitioners and patients during treatment, referral is warranted for sedation/GA
What is Parkinson’s disease?
- A progressive movement disease.
- The 2nd most common neurodegenerative condition in the UK (1st is Alzheimer’s).
- No specific cause, but there are risk factors including age (usually older than 50), gender (male), head trauma. Generally not hereditary.
What are the 3 types of Parkinson’s?
- Idiopathic
- Vascular
- Drug-induced Parkinsonism (caused by drugs which block dopamine)
What is the pathophysiology of Parkinson’s?
Degeneration and death of dopamine producing neurons in the substantia nigra (part of the basal ganglia).
What are the symptoms of Parkinson’s?
- Tremor
- Rigidity
- Shuffling
- Stooped posture
- Expressionless face
- Difficult initiating movements
- Depression
- Dementia
- Sleep disturbances
- Difficulty smelling
How is Parkinson’s managed?
Management of symptoms:
- Medicine to increase doapmine signalling in the brain, or to stimulate dopamine receptors e.g. Levodopa
- Deep brain stimulation, implanted device which generates pulse to stimulate parts of the brain affected by PD
- Occupational therapy
- Speech and language therapy
- Physio to aid muscle stiffness and joint pain
- Dietician to maintain weight due to dysphagia
Name the medications used to treat Parkinson’s and their possible side effects.
May be helpful to tip chair and then pt lies down instead of laying them back as the chair moves due to dizziness.
What are the dental considerations with regards to patients with Parkinson’s?
- Speech disorder
- Dysphagia
- Drooling due to poor muscular control
- Loss of smell/taste (early symptom)- may add lots of sugar to food for taste
- Bruxism- muscle rigidity and poor coordination
- Orofacial pain
- Dentures are often poorly tolerated
- Increased rate of caries and periodontal disease
- Repetitive tongue movements
- Xerostomia (reduced quantity and quality)
- Burning mouth
How may Parkinson’s affect dental treatment?
- Heavy emphasis on prevention: high fluoride toothpaste, for dysphagia SLS-free toothpaste can help (no frothing) - Oranurse
- Ensure messages between dieticians and dentists don’t conflict
- May have slow speech, don’t rush the pt and give them plenty of time to communicate
- Later stages of disease may be more suited towards community dental services
- Sedation may help with movements but need to ensure airway is protected
- Minimise risk of aspiration, especially in pts with dysphagia- 45 degree angle of chair, good suction, rubber dam, hand instruments instead of ultrasonic
- Consider accessibility of surgery e.g. stairs
