Neurodegenerative Diseases Flashcards
What is dysphagia?
Difficulty swallowing +/- pain
What causes dysphagia?
Associated with damage to CN IX - XII
Oral/pharyngeal pain, dryness, irritation
Tumours
Irradiation
Infection
Any condition that damages or weakens nerves or muscles involved
Who most commonly gets dysphagia?
Neurodegenerative conditions
Head and neck cancer
What are the potential complications of dysphagia?
Malnutrition/dehydration
Increased risk of aspiration (majority of people get some aspiration but more common in people with dysphagia)
How does dehydration lead to increased risk of dental caries?
Dehydration causes increased mucosal dryness and mucosal fragility. Mucosal dryness and decreased salivation cause an increased risk of dental caries
Dehydration also causes malnutrition which causes increased consumption of sugars which icnreases risk of dental caries.
Why does dysphagia cause patients to use more sugar?
Aerated drinks help in swallowing
Syrup is used for medications high in sugar
Thicker liquids are often used
Tablets are crushed and added to pureed fruit
Fruit juice used to breakdown thick saliva
Food pouching
What thickening agents are used for dysphagic patients?
Methyldextrose
Xanthan gum (lower caries risk)
How are patients with dysphagia managed?
Oral debridement
Reduced saliva/xerostomia
Oral pain management
Dietician (High sugar thickening agents)
Speech pathologist
Medical doctors
Multidisciplinary team approach
What is aspiration pneumonia?
Foreign material originating from either oral cavity or oropharynx descends into the bronchial tree and alveoli with colonisation of bacteria resulting in an infective process.
Dependent on amount and type of aspirant, frequency, and host immune response.
What is the burden of aspiration pneumonia?
Leading cause of death and hospitalisation in nursing homes.
Represents 1% of Australian deaths
Is dysphagia the main cause of aspiration pneumonia?
No, it is a risk factor but insufficient to be a sole cause.
What are the risk factors for aspiration pneumonia?
Immobile patients
Altered consciousness
Dysphagia
Comorbidities
Increased age
Oral health (may be a predictor of resp related deaths)
Nocturnal denture wearing (2 - 3x increase in risk)
Perio disease increases risk by 3.9x
Improved oral hygiene could prevent 1 in 10 deaths.
Can dentists make a difference in risk of ventillator associated pneumonia?
8-hourly oral hygiene reduced the incidence of ventillator associated pneumonia to 0 in stroke and neurologic ICU.
Cochrane review of 38 RCTs found chlorhex mouthwash or gel reduced ventilator associated pneumonia in critically ill patients from 24 - 18% no difference found for toothbrushing.
43 survivors of mild to moderate stroke had poorer periodontal condition on discharge from hospital after six months.
What should the dentist do for the patient with dysphagia?
Should aim to remove plaque from teeth
Increase protective factors against dental disease.
How often should oral hygiene practices be done in patients with dysphagia?
Should be completed at least daily after the last meal of the day
This includes the removal and cleaning of dentures daily.
How should mechanical cleaning be done for patients with dyspahagia?
Same as healthy patients.
Clean teeth and oral soft tissues including the tongue.
Brush around teeth at the gum level and in between teeth and chewing surface.
Use toothbrush, floss, interdental brushies, oral swabs, and gauze
Use less toothpaste (pea size)
Use higher fluoride products
How can protective factors be increased against oral disease?
Increased fluoride exposure
Address dry mouth issues
Use chlorhexidine based products for periodontal disease
How should patients with mild to moderate dysphagia be treated?
Where possible encourage normal oral hygiene: 2x a day brush. 1x interdental
If physical limitations supervise/assist, electric toothbrush, modified dental appliances, and suction/swab oral cavity to remove excess once completed.
How should patients with severe dysphagia be treated?
Risk is lower for decay but much higher for perio
Mechanical cleaning is still essential with brushing, interdental cleaning, and chlorhexidine + fluoride are useful.
Where maintaining some oral intake should complete oral hygieve after each meal.
Which people most commonly get MS and how slow does it progress?
usually females between 20 - 50 years of age and progresses for 15 years.
What are the common symptoms of MS?
Depends on region of the brain affected:
Bladder problems
Fatigue
Weakness
Muscle hypotonicity
Loss of sensation
Dizziness
Visual disturbances
Depression and emotional instability
How is MS treated?
Symptomatic management:
Interferon
Corticosteroids
Immunosuppressants (methotrexate)
What are the dental implications of interferon use for MS?
Can cause flu like symptoms, xerostomia, neutropenia, thrombocytppenia)
What are the dental implications of corticosteroid use for MS?
Affects healing of infections, can cause adrenal crisis (very low risk)
What are the dental implications of immunosuppressant use for MS?
Causes oral ulcerations, xerostomia, gingivitis, candidiasis, mucositis, anaemia, leukopaenia, thrombocytopaenia, and increased infections)
What are the oral manifestations of MS?
Trigeminal neuralgia (>40 year old females) can be bilateral or unilateral
Sensory neuropathy (Paraesthesia, dysaesthesia, and anaesthesia)
Paralysis (Similar to Bell’s Palsy - Usually a late symptom)
Why is it important to understand MS?
Patient may present with initial symptoms to the dentist
How can dentist help early detection of MS? What signs should a dentist look out for?
Question suspicious complaints about abnormal facial pains (20 - 35 year olds):
Mimicking trigeminal neuralgia
Numbness of extremities
Visual disturbance
Muscle weakness
Afternoon tiredness
If there is relapsing remitting pattern
Refer for neurological assessment
When should patients with MS be treated?
Ideally when in remission
With mild disease routine dental care is a good idea
When more severe: Transfer to clinic/dental chair, ensure good oral hygiene, prosthetic/reconstructive treatment, use short morning appointments.
What are the side effects of medications that commonly are used for MS?
Dry mouth
Some may cause bleeding problems
What should be considered for treatment of MS patients?
Stage of disease
Advice from other health professionals in multidisciplinary team
Implications of medications
Oral hygiene, risk factors
Access to dental clinic, transfer to chair
Short appointments in morning
Rational treatment planning
What brain regions are affected by parkinson’s disease?
Dopamine producing neurons in the substantia nigra.
Who most commonly has parkinson’s disease?
Men and more common with older ages. over 75 1 in 100 people
What are the symptoms of parkinson’s disease?
Abnormal shuffling gates. Difficulty initiating movements and stopping movements. Arms carried in front of body.
Bradykinesia (stiffer and slower movements) Pill rolling tremor.
Mask like face due to difficulty creating facial expressions
Dementia
Orthostatic hypotension
How is Parkinson’s disease treated?
Generally symptom management
Monoamine oxidase inhibitors used to improve early symptoms
Levodopa or dopamine agonists which are most effective and widely used. They replenish dopamine and improve motor functions.
Anticholinergics
NMDA receptor inhibitors (amantadine)
COMT inhibitors
What side effects are commonly seen in medications used to treat Parkinson’s disease?
Weight loss: Undernutrition
Altered speech: Slow, slurred, monotone
Abnormal swallowing/dysphagia
Change in taste sensation
Dementia
Angular cheilitis predisposition due to drooling.
When should dental treatment ideally be done for parkinson’s?
Earlier treatment is preferable because the condition does progress
What should be done to prevent discomfort caused by dysphagia?
High volume suction, patients come in the morning
What is huntington’s disease?
Progressive neurodegenerative disorder affecting the CNS.
Characterised by unwanted choreatic movements, cognitive decline and psychiatric disturbances.
Who does Huntington’s disease typically affect?
Males and females equally
6 -7 per 100000 in Australia
What causes mortality in people with Huntington’s typically?
Mortality is typically aspiration pneumonia and suicide
How is Huntington’s disease diagnosed?
Clinical sign with known history
Confirmed with genetic testing.
What are the symptoms of Huntington’s disease?
Triad of clinical symptoms:
Motor impairment (dysphagia and dysarthria)
Cognitive impairment (decline in cognition and memory)
Personality and psychiatric disorders (emotional) (Dysphoria, anxiety, sleep disturbances)
How is Huntington’s disease managed?
Symptom based and often moved to long term care in nursing homes and specialist unit daycare services.
Why is dental treatment so important to treat for patients with Huntington’s disease?
Aspiration pneumonia is a common method of death so dental treatment is important.
How is dental treatment applied to patients with Huntington’s?
Aggressive preventative measures and restorative treatment in the early stages.
Later stages: Domiciliary care and palliative care.
Oral hygiene techniques: Allow to maintain independence, carer assistance, individual tailoring of strategies, reminder posters.
What is motor neurone disease?
A quick neurodegenerative disease caracterised by selective degeneration of upper and lower motor neurones.
Also referred to as ALS or Lou Gehrig’s disease.
1900 affected in Australia
What are the challenges to dental care people with motor neurone disease face?
Patients with this condition require non-invasive ventillation meaning they might have a mouthpiece. Nasally delivered NIV is the only one that allows dental care.
Salivation and drooling with dry mouth and increased viscosity.
Dysphagia
Communication
Cognitive and behavioural changes (Can go from verbal to non-verbal)
What arrangements for dental management is required for patients with motor neurone disease?
Access to care: accessible facilities vs domiciliary visit.
Patient positioning: Upright and support head/body with cushions.
Communication
Treatment planning appropriate to disease
High volume suction for treatment
Appropriate oral hygiene and preventive measures
What should be discussed with other specialists involved in the treatment of patients with motor neurone disease?
Management of saliva issues (drooling and dry mouth)
Oral hygiene
Collaboration with speech pathologist regarding dysphagia management
Consultation with dietician regarding diet
